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Vrm s COj>)/ STATE OF CALIFORNIA " '- sr► <br /> DETHE RESOURCES AGENCY DO not# in <br /> PARTMENT OF <br /> Notice of Intent No. WATER RESOURCES NO. --" <br /> WATER WELL D 1 3r 3 4 6 6 <br /> f- cal.Permit Na.or Date. 1_ _ KILLERS DEPORT . <br /> State Well No <br /> (1) �W�I'F.R: Name --- Other Well No. <br /> Aa 2 (12) WELL LOG: <br /> Ci ry Totai de 5 <br /> from ft. to ft. Formatioa p .Depth of completed welt <br /> (2) LOCATION – (Describe by color, character, size or materia!) <br /> ,p <br /> cowry OF WEj,i, (See instructions); <br /> Well address if different from shove Owner's Well Number <br /> � - <br /> Township <br /> — l <br /> age_ <br /> Distance from .� Sectio <br /> c:des,roads,railroads,fences.aft <br /> (3) TYPE OF WORK: <br /> New Well�De pening ❑ _ <br /> s <br /> Reconstruction J; D <br /> Reconditioning 10 <br /> Horizontal Well 0 <br /> +` Destruction D (Describe <br /> 7, <br /> destruction material <br /> and <br /> Procedures in Item 18) <br /> -, <br /> (4) PROPOSED USE:` <br /> ODomestic <br /> Irrigation *� 0' <br /> S Industrial ~ ❑ ~ <br /> �L �/✓ Test Well ❑ - – <br /> 7 <br /> 1/1/I/IS +—,! Stock ❑' – – <br /> lV <br /> Municipal <br /> WELL LOCATION SKETCH 1 `_ .. Other ❑ �I – <br /> (5) EQUIPMENT: (8) GRAVEL PACK: _ <br /> Rotary ❑ Reverse yep No O <br /> Size <br /> Cable O Air ❑ Diameter of bore )' • <br /> Other ❑ from ! ( 16'..Bucket O Packd <br /> (7) CASING INSTALLED: (8) PERFORATIONS: <br /> Steel Plastic ❑ Concrete 0 Type of perforation or size of screen _ <br /> From To Dia. Gage or From To Slot <br /> ft. ft in. Wall ft- ft size _ _ - <br /> iu;� Z(e _ <br /> ' 61 <br /> (9) WELL SEAL: / – <br /> Was surface sanitary seal provided? YesrrO No ❑ If yes, to depth#�*. – <br /> FERMITZSERVI(-.FS <br /> Were strata sealed against pollution? Yes,2"' No O Interval ---Jt <br /> Method of sea Work started 19 Complet–I 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of Sat water, if know++ A This well was drated nder my furisdiction and this report is true to the bear of my <br /> Standing level after well completierL_ tt, knowledge and belief <br /> (11) WELL TESTS: SIGN$I) - r <br /> Was well test made? Yes-Q<�No ❑ If yes, by whom? a r) <br /> Type of test Pump— Bailer❑ Air lift❑ NAME "'�_� <br /> '.. <br /> Depth to water at start of test A, At end of tart ft » (Peaon,firm, ob or printed) <br /> Discharge gal/min after, hours Water temperature Address k' <br /> Chemical analysis made?. Yes 1 No ❑ If yes, by whom? 01y P <br /> Was electric log made? Yes No p If yes,attach copy to this report License No. Date of this report 11LIZ4, 44 <br /> DWR 188 :REV.7,76> IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />