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�.i <br /> I, <br /> S,A�DF CALIFORNIA <br /> TIdE RESOURCES AGENCY Do tiOf �1j1 tri <br /> DUPLICATE <br /> ii copy DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT �0. 313809 <br /> Notice of Intent No. Stat-Welt Na <br /> local Permit No.or Date Other Well No. <br /> DIF lop <br /> i (1) OWNER: me (12) WELL LOG: Total depth-c5-0-ft.Completed depth ft. <br /> Address ! from ft. to ft. r•'ormation(Des%:r by color,character,siu ar matertal) <br /> City <br /> r zip _ ' `t r A � <br /> (2) L ATl OF WELL(See instructions); <br /> r <br /> Cao Owner's el N be d - <br /> Well address it differon am above <br /> r / <br /> e r1 Q <br /> Township Range Section <br /> it _ M Dista from cities,rt� rai� fen etc. -—_ <br /> (3) TYPE OF WORK: <br /> New Well ❑ Deepening ❑ - <br /> � Reconstruction ❑ <br /> '_I/ Reconditioning ❑ <br /> Horizontal Well fJ <br /> VNL <br /> Destruction ❑ (Dewribe <br /> destruction materials and pro- <br /> cedures;in Item 12) <br /> (4) PROPOSED U _ <br /> Domestic - <br /> _.:.- Irrigation <br /> Industrial ❑ <br /> J Fest Well o ❑ <br /> RAunict ❑ - d <br /> giber <br /> WELL LOCATION SKETCH the) 1 <br /> (5) EQUIPMENT: RA CK: <br /> Rotary <br /> Reverse 13No Si <br /> G11nk ❑ Air ❑ of Ibore _ <br /> OI r Q Bac from - <br /> rr <br /> (7) <br /> iI <br /> Cfl. GSALL l8) PE <br /> Steel ❑ PaAtTy <br /> ndee <br /> From D CrWll <br /> size <br /> 0 <br /> _-_ <br /> - <br /> (9) WELL SEAL: /�' rl. - <br /> lf <br /> Wes,nrrfaee�ndrrywalprovided? Ye w( Na ❑ Ifymtodepth <br /> Were AraMwakdogtlmtpollution? Yet Ex Nn ❑ Inlerval��IC <br /> f <br /> Work started <br /> 193C Completed19 <br /> . � lulethai of aealing <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of lint water,if kliown Ll ft This well utas drilled under nl jurisdirrimt and Ihis report Is true to the <br /> j Standing level of ler well Completion _ ' - —It (lest of my k led a and belle <br /> I (11) WELL TESTS: �� Signed e1 ler} C1 <br /> Was well test made? Yen K Nn ❑ 11 yee,h whom? �y 4 t <br /> Y ul tet puce ❑ <br /> Biller Air hit ❑ NAME Grt I O!'t <br /> Depth <br /> p emn,Ilmt,aT—IMIaIign}rf wd n;printed) <br /> I]eplh to wafer at mart a(teal {I At end of test --It <br /> Address�2' �i/Z �o.n <br /> f)irclrarac grrl/nlinett t - larurs Water a armr // 6sT <br /> aLO /1L1_ Z1P S <br /> _ C�hemtal arutyrn made? Y� k No Ll if VM Ly whom? K Cay— <br /> NO ❑ 11 rw vHarh nr I tulhis refloat I.i4rllse Nn.� aL! ` U _ l)Illi`ul 11715 rPl>+vt -� <br /> Wuelerirlr made Yes ❑ �— <br /> It% ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIHEL9! NUMBERED FORM qy qy- <br /> `� pwR I"IR[V12-6e1 <br /> II <br />