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STATt?OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do Ilat ,Fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL ILLERS REO N0. 329076 <br /> Wlice of Intent Na � Y-160 to State Well No. <br /> Local Permit No.or Uate <br /> -5: L1_ een,_ Lt < Other Well <br /> (1) OWNER Na, ' (12) WELL LOG Tatal depth ft.Completed depth ft <br /> Address from ft. to ft. Formation(Describe by color,charic er,size or material) <br /> City ZIP _ <br /> (2) LOCATION OF WELL(See Instructions) 1 —7 — U <br /> County 14 TQ-t:A UIQ Owners Wel u ber V/ <br /> r 4 <br /> Well address if different from above �/ <br /> 51 <br /> Township:"4 VV_ Range ectlon 1 l — XZ <br /> D tance from qtses,roads,ra�llroads,fe es,etc. 1� te �I <br /> te <br /> r . L r w - �:- <br /> - ti <br /> (3) TYPE OF VORK <br /> MV-/ <br /> New Well W Deepening ClA^ <br /> I V-/ "�1 fiecanstructton ❑ <br /> �tI 11mondihontng ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> �} destruction materials and <br /> pro-cedures In Item 12) <br /> (4) PROPOSED US <br /> Domestic <br /> t y� Imgatton <br /> Industrial � ❑ _ <br /> 'fest Well ❑ <br /> r� ! Munici A <br /> WELL I OCATiO SKETCH �l�' �� 1 — <br /> (5)EQUIPMENT .GRA � CK. <br /> notary ❑ Reverse 13No I <br /> Cable ❑ Air ❑ tZi etc f bor <br /> Qther kr \ to a <br /> SI — <br /> (7)CASIVGIN5TAL (S) PER O Ti <br /> swd 11Piistla X of I r Ty n or size al Q <br /> FromT I Gage or t — <br /> ft ft t Wall size( - — <br /> "�i' <br /> (9) WELL SEAL <br /> Was surface samtaryseal provided? Y� Na ❑ If e;to depth, Ft <br /> Were strata scaled against lnlrona Yesl! r/ Iiterrd fL — <br /> Msthod of sealing 1 ork starte 13 CompletedfZ 19 <br /> (10) WATER LEVELS WELL DRIL R'S STATEMENT <br /> Depth of first water,if known fL <br /> S12ndin level after wellcom tenon ft This rue!l tugs drilled n my jurisdiction and tfirs report is true to the <br /> � P best of my_kn lerl !is <br /> (11) WELL TESTS <br /> Wss well test made? Yes ClNo X ff ya,by whore? Signed tlillor} .ter <br /> O <br /> _.� J" <br /> Type of test Pump ❑ Haller El Airlift El NAME TQ <br /> Deplhtowateralstart aftest it. At endo[test iL ® rrm reo ratron) ypedar ft <br /> ri <br /> Discharge gal/mrnafier haus Water temperature <br /> Address 121 <br /> Chemical analysis made? Yes ❑ No ❑ ff yes,by whom? Ctty ZIP <br /> Wasek.ctnelog made Yes ❑ No ❑ If attach toihisreport Ltcenseblo C DatooE[hisrepoit 6' <br /> SWR 198(ttnv 32-86) IF ADDITIONAL SPAC9 IS NEr=D00 USE NEXT CONSECUTIVELY NUMHEREa FORM <br />