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.mer obtained permit (�Vgraav� <br /> jn) <br /> adADRUPLICATF STATE"CA I'�' Do not fell in <br /> Use of comply with `� THE RESOURCd1 . AGENCY cp e <br /> localmgairameMs DEPARTMENT OF WATERSERso64 No. 168884 <br /> s„tie.of Intent N.. WATER WELL DRW,� OT�LTH State Well No. <br /> Local Permit No. or Dace FERMIT SERVICES °th”"``I N._ <br /> (1) OWNER: N;,n,e (12 WELL LOG: <br /> L r� ) Total dePtl�_k. Depth .f completed weI (t. <br /> Address 21500 Dustin Road fmm ft t. ft. Formation (Describe by calor, cbouneter, size or material) <br /> cry iodic Calif. 95240 zip 4 Top sail , sand <br /> - <br /> (2) LI�OCATION O� WELL (See instructions): <br /> Counyj JO8(,�'e�n __Owner's Well Number <br /> Well address if different from above -vm\`61a <br /> Township Range Sectio \,�' <br /> Distance from cities, roads, rafhoads,fences,etc. <br /> 92 -1 <br /> 1rerm clsy <br /> 1170 -1 \\ <br /> (3) TAWOIU , <br /> New W -876 <br /> Reconstruction ❑ 176 - lay <br /> Reconditioning ❑ B, e <br /> Horizontal Well ❑ - claX <br /> Destruction ❑ (Describe �\\ J- '\��,••, <br /> destruction materials and <br /> procedures in Item 12) - <br /> (4) PROPOSED USE:' 71 <br /> D.mrstie <br /> Irrigation' <br /> Industrial ��\�• ❑ _ _ , <br /> Test Well .-r� ❑ - - - <br /> Stock. .❑ _ - `\ <br /> Municipal j ❑ <br /> WELL LOCATION SKETCH \\' Other ;ice,, ❑ - -- <br /> (5) EQUIPMENT: (8) CBAVEL\\PACK: - - - <br /> Rotery Reverse ❑ Yes\\a No ❑ Siz <br /> Cable ❑ Air ❑ ter of bore P - - <br /> (>ther ❑ Bucket ❑ \ed'-Fro - <br /> (7) CASING INSTALLED- (8) ERFORAYIONS: <br /> \\\ \ <br /> Steel ❑ PWtic Co Type of pe or`dZe of stns <br /> From T Dia. Ga r F Tai <br /> ft f in. Wall ft ft <br /> (9) WELL SEAL.Was aurface sanNary sed provided? Yesg No ❑ H yes, to dePt6-6&—tt - <br /> Were Ebsta sealed against pollution? Yee ❑ No ❑ Inte I h <br /> Method of wally Work started-19— 19 '— <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of Cunt water, if is ft. This spell sues drilled under my furisdiction and this repose is true to the bert o% <br /> Standing level after -oil coarpleba ft. knowledge and belief. ) <br /> (11) WELL TESTS: SICNzo pr- . <br /> Was well test made? Yee ❑ No ❑ If yes, by wham? (Well Dn'Ber) _ <br /> Type of test Pump ❑ Bailer ❑ Air lift❑ NAME Calwatnr Dri 11 i n0 Cn_ IIID a <br /> Depth to water at start of tale ft. At end of tell h (Person, firm,or corpormtion) rrypd or printed) ' <br /> Durbarge gal/min after hOnle Water temperature alae_-- C+ Ki l way s�ga <br /> Chemical analyaia made? Yea [I No [I If yes, by whom? Cirty rPLrl prk Calif- ZiP-95 p <br /> Was electric log made? Ya No ❑ If yes, attach copy u thisreport Licenu No. 321252 nate of this repo <br /> DWR tee (REV.7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />