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Y <br /> STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not ,fill in <br /> Dile with DW» DEPARTMENT OF WATER RESOURCES <br /> 'WATER EL�LD R�T,LLRS M-TORT N0. 329073 <br /> atice of Intent No rr((l�� }� f{� State Well Na <br /> Local Permit Na or L7stn C[S S V 4 � y---'`�.1 fl�% u +C t if't,other Well Na _ - <br /> (1) OWNER Name Q%eV!29 S A c• (12) WELL LOG 'Dotal depth f► Completed depth � ft <br /> Addreas + /) from fL to ft Formation(Describe by color,chqxacler,sue or material) <br /> If <br /> City 71P q _ <br /> (2) L09ATION OF WE1,L(See Instructions) <br /> County r � y Owner's Well umber - <br /> Well address tf dt f ent from above �r7 45� r <br /> Tornsh-p -lf - Rangefection <br /> Dis anmfrorn cttiea r ds, a��tIJ�Wads fences,etG j � � -' e✓ stn' � <br /> r '1 W — <br /> �% t.✓� <br /> F (3) TYPE OF WORK y' j' rlekaI <br /> New Well)< Deepening ❑ — e <br /> Reconstruction ❑ r <br /> ReeondtUorang ❑ , <br /> �© Horizontal Well ❑ <br /> Destruction ❑ (Desenbe ' <br /> N. destruction materials and pro- r <br /> cedures to Item 12) <br /> f�L✓'� (4) PROPOSED US <br /> Domestto <br /> 'r <br /> Irrigation <br /> Industrial ❑ _ <br /> ! Test Wel! ❑ Q <br /> Mumct ❑ _ � <br /> O avyti �f <br /> WELL LOCATION SKETCH �f <br /> (5) RQUIPMENT k GRAV �CK t <br /> Rataty ❑ Reverse © \ No z <br /> Cable Q Air ] et of <br /> Exxo 0 <br /> O'bilo,J Other XL Buck rom <br /> (7) CASING INSTALL (8) PER O TI <br /> Steel ❑ ptastie Aavtp 1of Fo nor size of 9 <br /> From f Gage or t <br /> ft f i Wall t size <br /> r�! <br /> I:elk w <br /> (9) WELL SEAL �- <br /> Was surfacesanitary seal provided? Yes No ❑ If yes,to depth - ft - <br /> Were slratascaled aga But ? es o Inf I ft - <br /> Method of sealingl r ork started Ifl Cam acted 1fl <br /> (10) WATER LEVELS ''] J WELL DRILL 'S STATEMENT <br /> Depth of fust water,if known --- ter- ---- - --- - ft <br /> This well was drilled nder m jurudia wn and this report is true to the <br /> Standing level after well completion ft beat of ntyk OIII <br /> (11) WELL TESTS Stgned <br /> Was well test made? Yes ❑ No < If yes,by wham? } �j--(�Vo D ! r] <br /> ypeoftast Pump ❑ Bailer l❑ Airlift © NAME tl. f <br /> epth to waterat start of best ft At end of test ft. }r PC= f rm o orp lop]• printed <br /> Discharge gal/min after hours Water temperature Add r 4itr - <br /> Chetnlealanalysismade? Yes ❑ No ❑ Ifyes,bywhoar? City. 'Lc ZIP <br /> Was electric IM made Yes <br /> ❑ No ❑ If yes,attach co t0±21!122-ft- License Na Dnte of thus report t' <br /> DWR Lea IRHV 12-eaI IF ADDITIONAL SPACEi IS NEMIDED USE NEXT CONSECUTIVEMY NVIVIBeRED FORM � qhs <br />