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STAT 11 OF CALIFORNIA <br /> ORIGINAL. THE RESOURCES AGENCY Do not fill to <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 2994' 37 <br /> Notlee of Intent No State Well No. <br /> Local Permit No or Date, 9:2���� ��� -� r Qd/y' Other Well Nof/ <br /> (1) OWNER Name d 3 �Q (12) WELL LOG Total depth ft Completed depth f <br /> AddressC�'". from <br /> ft to ft Formation(Describe by color character,size ox material) <br /> city�,L� 9,0 4ep ZIP <br /> (2) LOCATION OF WELL(See Instructions) <br /> County `-�C1�.=,1 (LLQ —Owners Well Number W�' — <br /> Well address if different from above <br /> Township Range Section <br /> kirrign <br /> Distance from cities,roads,railroads,fences,etc '" <br /> �t <br /> — V � <br /> (3) TYPE OF WOIiTC 71y <br /> New Well Deepening <br /> �'��"�.-- Reconstru ton ❑ `a' �' �� <br /> Q Reconditioning ❑ L <br /> Horizontal Well ❑ " <br /> Destruction ❑ (Describe — d �- <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US _ <br /> Domestic — <br /> Irrigation V <br /> Industrial �\ ❑ _ <br /> Test Well \ ) ❑ <br /> Munlci �/ ❑ — � <br /> OA- <br /> WELL <br /> erWELL LOCATION SKE C11 < a ibe y, <br /> (5) EQUIPMENT CRA � CK <br /> Rotary ❑ Reverse ❑ No Si <br /> Cattle ❑ Air ❑ C et of baro <br /> Ther Buck Parked ram ► , tti <br /> � tip bt9 , ex <br /> (7) CASING I STALLED \ (a) PER O A7I <br /> Steel ❑ Plastic ❑ n rte Ty of fo r nor size " <br /> Froin r Giagt:OT \ O[ <br /> I'[ f 1 Wall t� Size — <br /> c O <br /> (9) WELL SEAL <br /> Was surface sanitary seal provided? Y No❑ If yes,to depth r ft. <br /> Werestratasealedagaiostpolluttan? [[Y--< No ❑ Interval r ft. <br /> Method of sealing ±' Werk stunted i8� Gompletoil 19 <br /> (10) WATER LEVELS. WELL DRILLER'S STATEMENT <br /> 1)apthof first water if known i� ft <br /> Standing level after wellcomptetion It This <br /> of mly dei under lief furtsdfctf and this r is true to the <br /> (11) WELL TESTS Signed JJ , <br /> AlWas well test made? Yes ❑ No ❑ If yes,by whom? (Weil D r1 <br /> Ypa of test Pump ❑ Rader❑ Airlift Cl NAMbrn ' Z <br /> Depth to water at start of lest ft. At and of test ft. (Pero f or ro ?ratio yped or printt.d) <br /> Dbctmrge go]/min after boors Water temperature A dress <br /> Chemical analysts made? Yes ❑ No ❑ If yes by wham? City CA21 � ZIP <br /> Was electric log Ida Yes ❑ No ❑ If ye;attach copy to this mpmt License No Dateefthisreport <br /> DwR 1813 IRRV 12-861 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM vt�S9 <br />