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STATE OP CAUPORNIA <br /> ORIGINAL THE RESOURCI=S AGENCY Do not fill in <br /> .*File With DWR DEPARTMENT OF WATER RESOURCES <br /> �j WATER WELL DRILLERS REPORT N0. 299438 <br /> Notice of Intent No Oe/ 3 State Well No. <br /> Local Permit No.or Date � Other Well No� <br /> (1) OWNED N... (12) WELL LOG Total depth 331 ft Completed depttt�'r► ft <br /> Address + from Ft to ft. Formation(Describe by color,character size or material) <br /> City �feaie-o ZIP ovo. _, <br /> (2) LOCATION OF WELL(See instructions) <br /> County Owner Well umber — <br /> Well address if different from above r <br /> Township Range Section — -ee 641i <br /> Distance from eltles,roads,radroa4 fences~etc — <br /> (3) TYPE OF WORK. <br /> New WCH Deepening ❑ <br /> JI Reconstruction © — <br /> n + <br /> Reconditioning <br /> _yLs� Hormontal Well ❑ <br /> D Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Itern 12) <br /> (4) PROPOSED US <br /> Domestic — <br /> Irrigation <br /> Industrial ❑ _ <br /> • 1` w-3 Test Well ❑ <br /> J iPU7 <br /> E)WELL. LOCATION SKETCH 3be) ,Fi V <br /> (G) EQUIPMENT 1 CRAY It CIC — <br /> Rotary ❑ Reverse 13 \ No\ f iv <br /> Cable ❑ Air ❑ eta of — <br /> t,7ther Suck ackcd rom !. <br /> 7) CAS4% LNSrALLED� (8) PER 4 TI \ _ <br /> Stcel ElPlastic ❑ a to Ty of an or size of r Q <br /> From T I Gage or T t — <br /> ft f I Walt t size <br /> i -.5c$ d r <br /> (9) WELL SEAL — <br /> Was surface sarntaryscalprovidedP Yes No ❑ IF yes,to depth '3 ft. <br /> Were stratasealedagainstpollution? 1( Na Interval ft <br /> Methodafsealiog ► 17f Work started 19 om leted F9� <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of First water if known �F/ __It. <br /> Standinglevelafterwellcompletion ft. This well was drilled under m Inrisdictwn and this report is true to the <br /> best of mil ouiledgit and b of <br /> (11) WELL TESTS signed <br /> IlWas well test made Yes ❑ No ❑ If yes by whoin? y i (We11 Driller) Y -- <br /> ypeoftest Pump ❑ Bader ❑ Airlift ❑ NA3YIE e t <br /> Depth to water w startof test it. At and of test ft (Po fi or tion)(Typed or printed) <br /> . Discharge gal/min after hours Water temperature Address ► <br /> a Pk <br /> Chemical analysis made? Yes ❑ No ❑ If yes,by whom? City 1 ZIP +S <br /> Was clectrtc log made Yes Cl No o If ym attach copy to this r rt License No Nate of this report <br /> OVrR TBS(REV i2-ee) IF ADDrnONA1. SPACE[13 NEEDED, USE NWff CONSECUTIVELY NUMBERED FORM � 9635•s <br />