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QUADRUPLICATE STATE OF CALIFORNIA Do not fill in <br /> Use to comply with THE RESOURCES AGENCY NO. 119240 <br /> focal requirements DEPARTMENT'OF WATER RESOURCES <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State Well Nn. <br /> (xo. <br /> / <br /> L. al Permit Nor Date= Other Well <br /> (1) OWNER: Nawr_ �' --_ 12 WELL LOG: '�''/ j/ <br /> r' ', ( � Total eicpth"� ft. Depth of completed well� Et. <br /> Address_" �` '7( -' • ' ,";..� li`-.,,• from ft. to ft. Fonnation (Des rile by color, character, size or material) <br /> ----._ -r--r---- --------- <br /> (2) LOCATION OF WELL (see instructions): j <br /> County Owner's Well Number <br /> i. <br /> Well address if different from abovr <br /> T,. -nship - flange Section____ <br /> \X41 <br /> DistatKe <br /> ection_._ _Distange fr-m tities, „ads, railroads,fences,etc -f - - <br /> NN <br /> b J <br /> I <br /> t.!� (3) TYPE OF WORK: f <br /> Kew %V ell tr Deepeningr <br /> ❑ r <br /> Bec nstnlction ❑ s: ,•.,, - - •'• '' <br /> HecnnditioninK ❑ <br /> j Horizontal Well ❑ <br /> -„ Destruction '.._.^ - <br /> ❑ (Describe ;:,. .. - •✓�", �. <. ;.. ... <br /> I destruction materials " <br /> .1 pr c du. in Item - <br /> } (4) PROPOSED - /'` <br /> i. <br /> Irrigation - <br /> III(lll\t rl:el <br /> i We" ❑ \ � - <br /> 1 ""c ti - <br /> Slunicip <br /> I <br /> WELL LOCATION SKETCH f Uthrr ❑ ' - <br /> (5) EQUIPMENT: (6) GAA PACK:. � - <br /> Rotan, ❑/ ReVerse ❑ ❑ Xu Size \-2 <br /> Cable Q' Air ❑ '` er of bore_ C - <br /> Other ❑ Bucket ❑ mm <br /> (7) CASING INSTALLED (S) PERFOIfA 'S. - <br /> Steel Q f'Lestic ❑ C( c c Type of pe n orWze of screeg'', _ <br /> ✓. <br /> From c — Dia. G' r r F `' T. <br /> fti <br /> . ff inWall all f. ft <br /> (9) WELL SEAL: , <br /> Was surface sanitary seal provided? Yes ❑ No ❑ If yes, to depth ft. <br /> i <br /> Were strata scaled against pollution? Yes ❑ No ❑ Interval ft. - _ - ! <br /> I 4ethod of sealingWork started l9_�_ Completed 19 ' 2 <br /> (10) WATER LEVELS: WELL. DRILLER'S STATEMENT: <br /> Depth of first water, if knew*'---- .___:i ft. This well wa. drilled unde, my inriedivtinn and this report is true to the hes( of my <br /> i <br /> Standing level after well completion '' ft. knowledge and belief. <br /> (11) WELL TESTS: StcNen <br /> a <br /> Was well test made? Yes ❑ No ❑ If yes, by whom?__. ... ----/---- (Well Dtriller) , j,,,� <br /> Type of test Pump ❑ Bailer ❑ Air lift❑ NAME___• J1{�•.,�Grose dIe(��l�I�l�, ,DTyr�ill inn _---. <br /> Depth to wnte•r at stun of test ft. At end of test ft 81 9( ar62,jT�'xr•7til2-d6 teed or printed) <br /> Discharge _ _ cal/min after hours Water temperature Address -- <br /> Chemical :malysis made? Yes ❑ No ❑ If yes, by whorl? '-.Clty--' <br /> �y 7y <br /> W:u c-lectric lox made? Yes C3 No ❑ If yes, attach c y to'this report. `License No. Date of this repot -al's <br /> DWR 180 1REV, 7-76, IF ADDITIONAL SPACE IS (NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />