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3riiler's Copy Notice of Intent No. Local Permit No. or Date[ 7-32$ w (1) OWNER: Nam. beatiQC STATE OF CALIFORNIA THE RESOURCES AGENCY DEPARTMENT OF WATER RESOURCES WATER WELL DRILLERS REPORT Address 3� Pala�or Ct. Can Bmmo Calif, � City � zin— (2) LOCATION OF WELL ( See instructions) : County SR Jnn (17111 Owner's Well Number Nell address if different from above Township T2S Range Re i Section Distance from cities, roads, railroads, fences, etc. Dirt extens Do not fill in No.24783 State Well No. Other Well No. ( 12) WELL LOG: 'Dotal dep�ft. Depth of completed we11i_.L1—ft. from ft. to ft. Formation (Describe by color, character, size or material) I$0 Stock ❑ , – Municipal , ❑ – Clav L shale S ale L;mnd s. ad ay 1d -lb ad ale ale & s and s. ale, id 1 (3) TYPE OF WORK: New WelIX Deepening ❑ Reconstruction ❑ Reconditioning ❑ Horizontal Well ❑ Destruction ❑ (Describe destruction materials and procedures in Item 12) (4) PROPOSED USE: Domestic Irrigation. ❑ industrial ❑ Test Well ❑ 103-:1-C lam- 1 112-11 11 12 – – 7 w 3= _ – – – – Stock ❑ , – Municipal , ❑ – Clav L shale S ale L;mnd s. ad ay 1d -lb ad ale ale & s and s. ale, id 1 DWR 188 (REV. 7.76) IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 43816-9307-7660M OUADdrosP WELL LOCATION SKETCH Other ❑ – (5) EQUIPMENT: Rota*, Cable ❑ Other ❑ Other Reverse ❑ Air ❑ Bucket ❑ (6) GRAVEL PACK: Yes M No ❑ Siz ore Diameter of bore.--- Packed. from Qto – – – - – (7) CASING INSTALLED: Steel ❑ Plastic [X Concrete ❑ (8) PERFORATIONS: hand cut. Type of perforation or size of screen (9) WELL SEAL: Was surface sanitary seal provided? From ft. To ft. Dia. in. Gage or Wall From To Slot ft— ft. size Were strata sealed against pollution? Method of sealing - ❑ No ❑ Interval ft. :7 (10) WATER LEVELS: Depth of first water, if know ^ Standing level after well completion 1=7 ft• 76 ft, - DWR 188 (REV. 7.76) IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 43816-9307-7660M OUADdrosP (9) WELL SEAL: Was surface sanitary seal provided? Yes_V No ❑ If yes, to depth___5J0_ft. _ – – Were strata sealed against pollution? Method of sealing Yes ❑ No ❑ Interval ft. Work started 14 19 �' Completed_ 19 (10) WATER LEVELS: Depth of first water, if know ^ Standing level after well completion ft• 76 ft, WELL DRILLER'S STATEMENT: This well was drilled under my jurisdiction and this report is true to the best of my knowledge and belief. SicNsn (11) WELL TESTS: Was well test made? Yes ❑ Type of test Pump ❑ No If yes, by whom? Bailer ❑ Air lift ❑ c (AVeU Driller) NAMEim21111nY5 °Bay • � Clb �— Depth to water at start of test ft. Discharge gal/min after hours Chemical analysis made? Yes ❑ No R At end of test ft Water temperature—Address If yes, by whom? � r—Ire, (Pe n, firm, or corporation vped o print ) ian ala_ Ave s – yAaIla City JOd P R to Gsa lif Zip O 5 2 5n • Was electric log made? Yes ❑ No Z If yes, attach copy to this report License No. ate of this repo rt iS-20-7Z— DWR 188 (REV. 7.76) IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 43816-9307-7660M OUADdrosP