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r) <br /> I4 � I <br /> ( •TATti Or CAL"RAHA t <br /> k ORIGINAL, G�C�r� � Tses"nESOURCrs ACENCY Do not 'dn z <br /> File with DWR ��� DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 358396 <br /> 5 <br /> f <br /> Notice of Intent Na Stab Will Ka <br /> it. <br /> Local Permit Na lar Data Otter Well NIL <br /> l (1) OWNER Nime I (12) WELL LOC: Total depth 6 RCome-ad&*ha=f <br /> Address from It to ft Formation{ !w b color,eltaraeta.alae ax mataelal) Y <br /> s City. ZIP <br /> l <br /> (2) LOCATION[OF WELL(Sr_e instructions): <br /> County Owner's Well Number - FSS <br /> Well address if different from above — <br /> 1 - Township s Range - Sectian <br /> ! Distance from ciliec rood;railroads,fences,etc- <br /> Y <br /> i h <br /> } <br /> (3)TYPE OF WOnr_ _ <br /> ICAl <br /> New Well�C(! Deepening ❑ — - S <br /> (° necvnstruclion Q _ r <br /> Remudilianing - Q <br /> .j Horizontal Well ❑ ,. . <br /> Dralrucllna ❑ (Describe <br /> + - destruction materials and pro. Aff, <br /> cedures.In Item 12) <br /> + <br /> i. (4) PROPOSED USE . <br /> Domestic - <br /> -_.�i Irrigation Q _ <br /> Industrial a <br /> .Test ❑ r i . <br /> 3 <br /> f - _ Municipal ❑ _ �iCIE <br /> f <br /> Oihcr ❑.). ` — tib" <br /> -;f wEL�tACAT1ON SKETCH <br /> p - (5)EQUIPMENT:� {6}CNAVELPACK: �. - \ '•r ' <br /> t x� Rmary❑ li lt.verr. ❑ 1q No St:e 1 '- ..1 - <br /> 1 ❑ <br /> 1 odd Buckrl.� i'acy�from -10 fl 1 <br /> i <br /> s Cr)CASINC INSTAsR te)PFJ:Fo[tATlot .. - 1 <br /> Slod Ili.. ❑ Cpner.le,[} Tyr-efltp lesion&size at yersaa✓,,, _ ) <br /> From TO r_ 1} Cage or. Cliartl ' Tv <br /> IL [T,'I\ int ' W all f t'• 1. /size <br /> ! <br /> } <br /> (9) WELL SEAL — <br /> t 1 1 i <br /> Was ewfw nsitry aw pro-"? Yes O No a ttMtodeph----- k — <br /> _ Waraaustas- lesafarpeawio.? Yr E.] No❑ Inte.v.1 Ic <br /> Um6odofte.IirK Work startrd - <br /> 1 (10).WATER LEVELS: r WELL DRILLER'S STATEMENT: <br /> S Deµb at letat Wat.r'.l u i,wvn_�,, EL n - <br /> Slatdingiev.lafter.eCane ton ThA ruff rues drtllyd undt m /err lion and Au rrpor•a tru!!o aw <br /> ,W ----�� It brat of m rdg ORri`!fs/. �t <br /> 1 i (11) WELL TEM: <br /> Sigrd1L�(1 <br /> Wea"Itt.r msdal Ya❑ No❑ 1f y.c bham? <br /> Typsdl+r_ - harp❑ 6tlirr - Alliin ❑ NAME <br /> i awk 1*.01"N SAA of It rL At c of tw—' In (Perry!trot a oorporuloo)(TY err 1 .. <br /> # 1 Di",!Sa' µl/osinafter hw Watntempe..tun Addreaa <br /> Grmlra�wlySs eudaT Yet Q No U If M by rh—T Gty ZIP <br /> i - I W.s eLar lc log m.de_ Yd Q No Q__ [i yet■meh mpy_w_this n .. License Na - Deter d Ilrlt r.+tn.t <br /> r <br />