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' 7 <br /> STATE OF CAUFORN1A <br /> ORIGINAL THE RESOURCE=S AGENCY Do not fill to <br /> File with GWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 339229 <br /> 4,116otice of Intent No. State Well Na <br /> Local Permit No,or Date f Other Well No.� � <br /> (1) OWNER Nemo r (12) WELL LOG Total depth ft Completed depth ft, <br /> Address I�Q z S AV bcv=oto -S from fl, to ft Formation(Describe by color charneter,size or material) <br /> City ZIP p _ f <br /> (2) LOCATION.OF WELL (See Instructions) — <br /> County 40 ar/OQ9!w N Owners WeliNumber <br /> Well address if different from above G <br /> Township. !VAJ ._ — Range ii- A 6 Section <br /> Distance from cities,roads,railroads;fences,ctr- - <br /> -- smvaSiiieir - - - - - - S <br /> 4 1 <br /> _ 28,Se — S D L- <br /> 1(3) TYPI;or WOAIC <br /> a I sNew Well El Deepening ❑ ' L <br /> ` 'Reconstruction © - <br /> ` Reconditioning © Q T <br /> T Vonzontal Well <br /> (Destruction ❑ (Describe - r <br /> i I <br /> =Ion materials and pro- <br /> S� <br /> y R 4 I "I �{'' 6 �cedures in Item 12) <br /> 1 ,(4) PROPOSED US _ <br /> -��a1 a e1 I I ' Domestic <br /> 7 I <br /> ti 1 ` ! �• I Irrigation <br /> r 1 <br /> (Industrial ❑ - <br /> '•^�- Test Well ❑ <br /> a+'a VVV <br /> ZZ ❑ - <br /> ' I o rr <br /> - - - WELL.LOCATION sKETcH Y b%.) - <br /> (5) EQUIPMENT 1 GRAY CK. <br /> Rotary ❑ Revasso ❑ ` Na i <br /> Cable ❑ Air ❑ e! of bare <br /> Other Buck � ed mm 16, w <br /> 4-b I AbrVZt< 6X <br /> (7)CASING INSTALLED-" (8) PhR07�lt r <br /> Steel ❑ rlastle No ret Ty aonarsizeof <br /> From T i Gage or It <br /> ft f t Wall t size <br /> r u <br /> (9) WELL SEAL <br /> Was surface sanitary seal provided? Yes�g) No ❑ If yep,todepth ft <br /> Werestrntasealedapuistpullition? YrsP2 No Interval <br /> Method of Haling Work s[artecl ~` �19 Com let <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water,if known fl i <br /> Standmglaveiaftorwclicom tet+�+�i_.... _... �. ft This well wns drilled under mV jurisdiction and this report is Ines to the <br /> p best of my knamlt aril f��d <br /> ( <br /> (11) WELL TESTS _ <br /> test made? Yes❑ No 9V if yes,by whom? Signed { 11ri] r) <br /> 4t,;7.-,,:0St <br /> Pump❑ Bailer ❑ Airlift ❑ NAME W A4pthtawalaratstar{oftest-(t At"MI oFtoll II {Pe firm arch rajian) orpnn ) <br /> Discharge gal/min after hours Watertempernturu Address �( <br /> Chemical analyse made? Y->0No❑ H ym by whom? I City CA ZIP <br /> �/ +� <br /> Waselectric log made Yes ❑ No If yes,attach ropy to this report License No, 5S L!T�C L--L—-Date of thts report Z �� <br /> DWR reel)REV 12.86) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSSCLMVELY NUMBERED FORM 66 96333 <br />