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QUADRUPLICATE STATE OFCALIFORNIA Do not fill in <br /> Use to comply with THE RESOURCES AGENCY <br /> ^wcal requirements DEPARTMENT OF WATER RESOURCES <br /> Notice of Intent Na. ��� <br /> WATER WELL DRILLERS REPORT State Well No.No. 118390 <br /> _ <br /> Local Permit No, or Date <br /> ---- <br /> Other Well No. <br /> (1) OWNER: Name %f, >�i{/ _ - %L = 12 WELL LOG: qq )) <br /> /' ( ) Tota]depth`�>"rt. Depth of completed wen.a'`�'rt, <br /> Address �7-/ 7 from ft. to f. Formation (Describe by color, character, size or material) <br /> Y � , <br /> (2) LOCATION OF WELL (See instructions): <br /> County =�-' Owner's Well Number 7--- lo n-" `•e'^/�= <br /> Well addrtss if fdifferent Com above la`� - /J' (G - %,4'%;'c. <br /> Township Yom/ Range / � ceello 5c6 <br /> Distance from cities, mads, railroads,fences,etc. <br /> ['. 7nA/ ,�icE:7.va' �F i'✓6c.TiE,c:. ,� > /7%' - / ;' "�.rc: _ _. .: <br /> (3) TYPE OF WORK: ' <br /> l� New Well ❑ Deepevivg-t Al C.,' <br /> Reconstruction <br /> Reconditioning ❑ - - -. «;- - /"t - <br /> Horizontal Well ❑ - <br /> Destruction ❑ (Describe - <br /> -- destruction materials <br /> ---�---- procedu+es in Item - <br /> (4) PROPOSED 7, <br /> Domestic <br /> IndustrialLlWell ❑ _ <br /> Mumc'p 11 <br /> _ <br /> WE LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRA PACY: <br /> Rotary ❑ Reverse ❑ ❑ No Siz - <br /> Cable 1}f. Air ❑ erofhere - <br /> Other ❑ Rocket ❑ m - <br /> (7) CASING INSTALLED- (8) ERFORA S: - <br /> Steel Plastic ❑ C( c Type of pe n or a of scree - <br /> From T Dia. r F To - <br /> fL fq >in. Wall ft. <br /> (9) WELL SEAL: �[ - <br /> Was surface sanitary seal provided? Yes No ❑ If as, to depth - .Ifr, - <br /> Were strata sealed against pollution? Yes ❑ No P( Interval R. <br /> Method of seelin Work started 19 - Complet d �z-r 19 <br /> (10) WATER LEVELS: 16. WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know This ell i d,HIM under my jurisdiction and this report it to,, to the best of my <br /> m <br /> Standing level after well copletlo R. krruwledge a <br /> and belie). <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No 0( If yes, by whom? (Well Driller_) <br /> Typc of test Pump ❑ Bailer ❑ Air lift ❑ NAME /� < "'•''!�.-/�'� ' <br /> Depth to water at start of test ft. At end of test ft leer.+�n, fine, ."'rpomtion) 'ped or <br /> Print ) <br /> Discharge va]/min after Lours Water temperature Address— <br /> Chemical <br /> ddress Chemical analysis made? Yes ❑ No H as, by whom? City ' _ Zip <br /> Was electric log made? Yes ❑ No If yes, attach copy to this report License No. Date of this report <br /> DWR 188 (REV. T.ra) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />