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i <br /> r <br /> t STATE OF CALIFORNIA <br /> ORIGINAL ~ THE RESOURCES AGENCY Do not fill in <br /> File with DW9 DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 319612 <br /> 0-tice of Intent No. State Well No, <br /> Local Permit No or Date Other Well Na+.40 ' ° <br /> (1) OWNER Name CM0\ � (12) WELT.. LOG Total depthfL Completed depth ft <br /> Address from ft to ft rannatton(Describe by color character,size or material) <br /> City. tl CL-AZ ZIP <br /> (2) LOCAT O�N OFF WELL (See instructions) <br /> County�i0-4 Owner s W 11 Number # <br /> Well address if.d- � V <br /> iffe�yrs�t from above 44)a <br /> � <br /> Township� Range.-R4- d6, Section <br /> Distance from cities,roads,railroads, fences eta <br /> (3) TYPE OF WORK <br /> New Well P&,Deepening Q <br /> y Reconstruction 1164/c Recondttiorung 0 <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> ddestruction materialsand pro� ceduresdures m Item 12)2) <br /> L (4) PROPOSED U5 _ <br /> Domestic _. <br /> Irrigation <br /> Industrial p _ <br /> Test Well < 0 Q <br /> Svlunicl !] <br /> a er <br /> WEI L LOCATION SKETCH <br /> (3) EQUIPMENT AV fN CK <br /> Mary [I Raver"' <br /> Cl No rz <br /> fable ElArr (~] ele f bare <br /> Oth r Buck df <br /> romm t <br /> - �-�. Rt, <br /> (7) C1SINCINSTALLF.4 (8) PER OR TI c - <br /> Steel ❑ Plastic et Ty" fo an ar Site 4 <br /> From T .,)iA Cage or r t <br /> ft. f t Wall size <br /> (9) WELL SEAL �- <br /> Wussurfawsanrtary seal provided? Yes No ❑ Ifymtodepth ft <br /> Werestrataspted¢galnst ]lutlona Yes Na 13 interval d ft - <br /> Methodofsealtng n t7� '� Work started 19 Completed I9 <br /> (10) WATER LEVELS WELL DR R'S STATEMENT <br /> Depth of first water if known fe <br /> Standen level after well completion ft Thls tuell s rifled under rn jurisdiction and this report is true to the <br /> g p best of g wledge and belie <br /> (11) WELL TESTS Sign <br /> Was Weil test wade? Yes Q No�II yes,t whom? g r _! � (W 1 �^ <br /> attest Pump ❑ finder Q Atrhft ❑ NAM E`•®' <br /> �thtowateratstortoEtesl ft At end of test ft 0 r ra )( ]medorpr ted) <br /> 46 Discharge gat/mm,dter hours Water temperature Address <br /> Chemical analysis made? Yes 0 No ❑ If yes',by whom? Uty ZIP r�r��` ^� <br /> Was electric tog made Yes Cl No © Ifyes,attacheopytodusro ;r`rt License '� Date of this report 4 'z <br /> 91 <br /> OWR ISO IRgy 12-S6I IF ADDITIONAL. SPACE 13 NEEDED VSE NEXT CONSECUTIVELY NUMBERED FORM 96 96353 <br />