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DUPLICATE <br />STATE OF CAUFORPRA <br />THE RESOURCES AGENCY DO riot ff(I in <br />Driller's Copy <br />DEPARTMENT OF WATER RESCPURGES 3 <br />WATER WELL DRILLERS REPORT N0. 374007 <br />Notice of Intent No.State <br />Well No. <br />Local Pcrlmit No- or Dat <br />Other Well No. <br />(1) OWN v�acge t <br />(12) WELL LOG: Total dep b. Completed de ft. <br />Address <br />from It to ft To[matio (Describe by color, character, size or matorlal <br />— <br />City C <br />ZIP <br />(2) L ON_QF WELL (gee irutsu <br />tzons): <br />— <br />County O-jaej <br />s Well Number <br />Well address if diffor A frUrt; a ve <br />Township Range <br />Section <br />Distance from cities, roads, railroads, fences, etc. <br />_ <br />(3) TYPE OF WORE: <br />New Well Deepening ❑ <br />Ite�strirction ❑ <br />Rccan"ooing ❑ <br />Horizontal Well. ❑ <br />Dmtructivr, ❑ (Describe <br />destruction materials and pro- <br />ceduro in Item 1]) <br />(4) PROPOSED US . <br />_ <br />(Domestic <br />_ <br />tuigation <br />IraJ.urtai.l ❑ <br />Test Wel . O Q <br />Muaicl ❑ <br />er <br />lbel <br />— <br />WELL LOCATION SKETCH <br />(S) EQUMMENT: <br />Rotary/� R,4m ❑ <br />t;K <br />CtC: <br />No lz <br />Gb1c Air ❑ <br />of bore <br />Otber ❑ Bucket -0m <br />— <br />(7) CASING E4STALI <br />steel ❑ Plastic <br />Type of <br />or size of Q <br />From I Gage or <br />T <br />— <br />ft. f i Wau <br />t. <br />(9) WELL SEAL: <br />Was mrfars• —Mary anal provided? ycs No ❑ <br />if yer, to JgAJk� .: It <br />— <br />— <br />Were ox t. soled abaimt ? yes No <br />Interval It <br />Work starkeai Com leted ]9 <br />Method 4wAlta` <br />(10). WATER LEVELS: <br />WELL DRILLER'SjTATLF <br />Depth d fir,t water, if krta-n .: <br />ft <br />This welt was dri om and this report is true ro the <br />staodi%kvcl rf ter rr.11 oompkhtim <br />It <br />beat of my know . <br />(11) WELL. TFM.y <br />Was well tat mock? ' Yu ❑ No XJ' If yea <br />Type of tort Pump ❑ /.` Halter <br />Depth to water at start of tat It <br />whom? <br />b Air lilt ❑ <br />At ervf of test ft <br />signed54 <br />W ilkr <br />NAME <br />tion} or intcdl <br />(ersor, (TY R <br />Discharge gal/Quo after hors <br />Watar tempruatvre <br />Address <br />clwnslcal analysis made? Y..r ❑ No El if yes, <br />y wham? <br />City. _ Z1F <br />Was electric log mad.. Yes ❑ No ❑ If ya,. <br />6 o py bo this re pxt <br />License Na Date of this report <br />IF ADDITIO <br />owa POD (RMI 12 -aa) <br />L SPACE 13 NEEDED, USE NrXT CON3CCUTIVELY TrUMMEFMD FORM Pars? <br />