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J <br /> STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 299436 <br /> Notice of Intent Na SMte Well No <br /> Local Perini Na or Date - Z` '{ °7 ..Q _/Ji Other Well No <br /> (1) OW ER Name fi htGs (12) WELL LOG Total depth ft Completed depth r ft <br /> Address <C7 4 from ft to ft Formation(Describe by color,character site or material) <br /> City SQ AJ a LO Q 'LIP VW02L _ <br /> (2) LO TIO OF WELL(See instructions) r t7 t! <br /> County Owners Well Number — t'► fit <br /> Well address if difleren from above +' Zxv — <br /> TownshipRange Section L g b r <br /> Distance from cttie%roads railroads,fences etc. <br /> r .5 irc�titeS CtC�t- <br /> -- <br /> (3) TYPE OF WORK <br /> New Well Deepening ❑ — i' <br /> Reconstruction ❑ ik <br /> nReconditioning Cl <br /> SidHorizontal Well ❑ -' <br /> Destruction ❑ (Describe Ne <br /> destruction materials and pro- <br /> (A cedures in item 12) <br /> (4) PROPOSED USCEX _ <br /> Domestic / <br /> 4 Industrial <br /> 4-1 <br /> Testi Well <br /> Irrigation <br /> l ❑ — <br /> Test Well ❑ <br /> ,r Munici0�1 ❑ <br /> — <br /> WELL LOCATION SKETCH x .1e b t} <br /> (5) EQUIPMENT k)SG RAl+ C K Mary ❑ Reverse ❑ � N0 i <br /> Cable ❑ Air ❑ c eta of 1>nrd <br /> other Backe ro t S \' — <br /> (7) CASING INSTALLED- (a) PER OR Q \ <br /> Steel ❑ Pluiseat T of on orsim of r <br /> From TGage or �j t <br /> ft f C i i Wall t size <br /> 0 35r sem! Q , o'Z. <br /> (9) WELL SEAL — <br /> Was surface sanitary seAprovided? Yes No Ifymtodepth 1� ft. <br /> Were strata sealed against pollution? les No O Interval + ft — <br /> Method of sealing Wor&started I9 Com letcel 19 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water if known - - ft This well was !ed trader I fur c and thfa r ori is true to the <br /> Standing level after welloompletlon ft best of-Y dge and U <br /> (11) WELL TESTS Signed <br /> as well test made? Yes ❑ No ❑ If yes,by whom? (W�1LQn <br /> ypo of test Pump ❑ Boller ❑ Air lift Cl NAME <br /> Depth to water at start of test ft At and of test ft i (P Miqor corp i it(Ty or printed) <br /> Discharge gal/mm after hours Water temperature Ad e�stis � <br /> Chemecaianalysismade? Yes [) No ❑ Ifyes,bywhom? Ctty L'?a mmoy3 n ZIP ISA-k 1.1 <br /> Was electric log made Yes ❑ No ❑ If yet attach copy to this repott iLicenseNo G Date of this re rt <br /> OWR 1013(1113y 72436) IF ADDITIONAL.SPACE IS NEMKo VSE NEXT CONSEC�r3 ' NUMEAERE0 FORM 06 9633; <br />