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QUADRUPLICATI: 17 <br /> STATE OF CALIFORNIA � DO not fill to <br /> Use of comply Will THE RESOURCES AGENCY t1� <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 168812 <br /> Notice of Intent No.—OZ-1940 WATER WELL DRILLERS REPORT state Well No, <br /> local Permit No. or Date Other Well No. <br /> (1) OWNER: +,.._.. (12) WELL LOG: Total de,th135-ft. Depth of completed -A36--ft. <br /> Address___,__ from ft. to ft. Formation (Describe by color, character, size or material) <br /> City - _ �► Zip 0 3 Sand <br /> - <br /> (2) LOCATION 011 WELL (See instructions): <br /> Onm— • Owner's Well Number - _ <br /> 4 Well address if different from above' 28 - 2 may <br /> f Township ungSection_ 36 w.71. 1 ,!' <br /> Distance from cities,roads, railroads,fences,etc - 1-27 <br /> (3) TYPE OF WORK: 1-9 <br /> New WeII X Deepening ❑ <br /> Reconstruction 0 _ <br /> Reconditioning ❑ _ <br /> Horizontal Well El _ <br /> Destruction ❑ (Describe - r <br /> destruction materials <br /> Procedures in Item <br /> (4) PROPOSED SE - '�313 <br /> Domestic ,{ _ ti <br /> Irrigation< < ❑ <br /> Industrial ❑ <br /> Well ❑ _ <br /> Stoc _ <br /> Munich, —,- v <br /> WELL LOCATION SKE'T'CH Other ❑ - <br /> j (5) EQUIPMENT. (6) GRA PACK: <br /> Rotary + ] Reverse ❑ No S' <br /> Cable ❑ Air <br /> © ra�, er of bore _ <br /> Other ❑ Bucket ❑ Z. <br /> (7) CASING INSTALLED _ <br /> Steel 0 Plastid] Co a Type of perli�r n 017lze of scree;k� <br /> From T Dia. Ga r Ffi . `�. 'To <br /> ft. f i Wall ft-'O , ft. s• _ <br /> 160 11 <br /> PSI - <br /> (9) WELL SEAL: _ <br /> Was surface sanitary seal provided? Yesn No ❑ If yes, to depth—%--ft. _ <br /> Were strata sealed against pgllu�ion �Y�es■( No ❑ Interval ft. - <br /> Method of sealin A •i Work start19 Comple L <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first_water, if know ft, This well was drilled under my jurisdiction and this report is true to the best of my <br /> Standing Ievel after well completion— knowledge and belief. t <br /> (11) WELL TESTS: SxcxEn r. <br /> Was well test made? Yes ❑ No ❑ If yes, by whom? (We Ddlle ) <br /> Type of test Pump ❑ Bailer© Air lift ❑ NAME F rr .11 ng Go.f Inc• <br /> Depth to water at start of tesR. At end of test--L----ft o firm ration) (Typed or printed) <br /> Dischar a gal/min after--hours Water tempera Address <br /> g <br /> Chemical analysis mado. Yes City UM , Guar Zip 0 <br /> ❑ No ❑ If yes, by whom? <br /> ---6-3-137 <br /> .Was electric log made? Yes ❑ No Q If yes, attach copy to this report License No, Date of this report <br /> DWR 188 (REV.7.75) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />