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STATH Op"UMFINIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill to <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 323806 <br /> Notlem of Intent No. r-r State Wall Na <br /> Local permit Na.or Data ��` �-� Other Well <br /> (1) OWNER: N 6'1' b t (12) WELL LOU: Total dept It.Completed depth_,ft, <br /> npAddress ,p from it. to R. Formation(Describe by color,character,size or material) <br /> City ZIP ZIP —•% <br /> (2) LOCiT10N OF WELL See Instruetlons); —MS 4 i <br /> Ccunly t7` Owner's Well Number 73 1 — 'Ss� <br /> Well address If different from r ove <br /> Towmhlp 6 f iff Saotion OP-44 <br /> Distance from cities,roads,milmarls,fence i etc. S <br /> (3) TYPE OF WORK: — <br /> Now Welix Deepening ❑ <br /> Reconstruction ❑ - <br /> � <br /> Recondittoning ❑ <br /> Horizontal Wall ❑ <br /> Dostructfov (Deserlbe <br /> dostruetionn.5urials and pm- <br /> cedures t gm� 2)` <br /> (4) PRCS iS , <br /> Domestic <br /> I �'S\ \S1 RqP <br /> ndustlo I — <br /> Test I <br /> lO ❑ <br /> Test Wel ❑ <br /> Mnnlcl 1 ❑ Q <br /> O <br /> or [(� <br /> WELL LOCATION SKETCH <br /> (S)EQU1PhN1..EINTt ORA CM <br /> Nawly.ctnevoren ❑ �` No x <br /> Qblo C3 Alf [I \ IQ ale f ham <br /> Other ❑ Backe ram b <br /> (7)CASINO INSTALLED: (S)PER Oil 1 _ <br /> SI¢dl ❑ Plnsti e! 7} of onorsixee[ Q _ <br /> From T DI . Cage or T t <br /> ft. f C wall t. size <br /> (9) WELL SEAL: — <br /> Was mrfacasmitoryreelprovided? Yes No❑ Ifyeglodopt R <br /> Woreetretasealed sgaimtpol uum? To Ne❑ fmcsml It <br /> Mathodafaaalirtg Work started— ID� Com klpl 10 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water.i(kaowo it <br /> SWndin loreto(torcvdi earn leiton fe This well toes drlfleel under m fnrfadkdan and this report 4 true to the <br /> e P hest of mu knowledge a d Kite. <br /> (11) WELL TESTS: Signede <br /> Wmwelllastmaile? Yee❑ No❑ Ifycs by, hem? �// aIDd <br /> 'aqvFYp..(lost Pump El Bake U Atrllft ❑ NAME t�17'-� (7 �.1' H/!✓C,J1+1.f <br /> Depth to wal¢eatatertof lest�it fmpR <br /> wetrtdim <br /> Rem',e'r¢ ml on)(T arprtnl¢d <br /> DlscMrge�_gnl(misafter.__hoars at¢rfemaratme Address jg5b � <br /> (lumfleal analysts made? Yea ❑ NaR. Ilyes,bywhom? ZIP <br /> Woseleculelogwade Yes N039 Ifyos,nuacheawolbb"pat Llrxnse Na,_3�� �`-S Date of lhkroport <br /> DWR lots MV.1310) jig ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 84 96155 , <br />