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QUADkUt•�n.Af c <br /> Us:: to comply with v STATE OF CALIFORNIA �1 <br /> local requirements THE RESOURCES AGENCY Do not fill in <br /> DEPARTMENT OF WATER RESOURCES No. 42813 <br /> Notiee of Intent No• WATER WELL DRILLERS REPORT <br /> Local Permit Well No. <br /> dt No.or Date ) / <br /> Other Well No. <br /> (1) OWNER: Name ` 12 WELL LOG: <br /> ( ) Total depth (t. Depth of completed wet!r_+ <br /> Address � from ft, to h. Formation (Describe by colm, character, size or material) <br /> City I E�L�/rrY iPd4 t <br /> (2) LOCATION OF WELL' ( ee Sinstntetions): t — <br /> County \! f 4 �_Ownse.Well Number — - - ... i <br /> Well address if different fru 1% /? - <"'- . <br /> e <br /> Tu.vnship j: 1 _Range Sectio /:. '� - /'. 1_ '� <br /> Distance floor cities, nreds, railroads, fences,etc <br /> (3) TYPE OF WORK: <br /> New Well$. Deepening ❑ 4 _ <br /> Reconstruction ❑ _ ,( ,r <br /> Reconditioning ❑ /, _ t/ <br /> Horizontal Well ❑ - -` '� y <br /> I <br /> Destruction ❑ (Describe - is <br /> destructionateriale ', <br /> procedures in Item <br /> (4) PROPOSEDI <br /> Domestic 7 <br /> Irrigation <br /> Industrial ❑ _ --' <br /> Telt Well ❑,.'•'.. <br /> stuck [] _ <br /> Municipal ❑. �_ r <br /> WELL LOCATION SKETCH :', Other ❑ - <br /> (S) EQUIPMENT: (B) GRAVEL PACK: - <br /> Butary ❑ Reverse ❑ _ ,YT ❑ No s] Srze <br /> Cable .A., Air ❑ _II mater of bore <br /> Other /❑ Bucket ❑ - adfmm t <br /> (7) CASING INSTALLED"-,, (8 PERFOR sftONS; <br /> Steel Plastic ❑ Type of pe ~tion n}:6ize of scree - ) <br /> From T •-- Dia. r F� � To <br /> ft. f (`' in. Wall {6.`,-` .+, ft. <br /> 1 <br /> (9) WELL SEAL: r <br /> Was surface sanitary seal provided? Yes)E) No ❑ It yes, to depth�ft. - <br /> Were strata sealed against pollution? Yes LI No Lj Interval it. <br /> Method ,I seahm' i Work starts — Iti'' Completed .., /� 3B. <br /> 110) WATER LEVELS: I WELL DRILLER'S STATEMENT: <br /> Depth of first water, If Auox'a �yr} It. ']'his mall u'ru drilled uode•r o, iurivdiouln mud thi, rnwn n ruc ,, the best of ma <br /> Standing level site, well cmmnletiun_ r).."` ft. -4- <br /> ArruAedac and beim/. <br /> f ll) WELL TESTS I Si <br /> Was well test nrnde' 1 VV I-j No)Q If e'. by xhoms? .'L"11 U II <br /> Type of trot Pump LI B: ler ;_I All till <br /> Depth to water at xtar, nt text. _It At end ut tea It I I Y./nun, firm r s rocs r I y 1 Pmi s r 1p toll J <br /> 'Awoocd nnnlvxrs nudc? Yrx I I to I I n .roc, by .vbuuo+ __j •�-'--t=-r---1-- (-� / - - - <br /> Was electro la¢load"? Yes f I No n If sex, attach rr I. m this wi rt 1 1 ue N _.-�---- <br /> _._ . . _ .__.._ __-_ __ ._..__ : <br /> OWR 188 •Rey. >.>1' IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM ,,.u...-- ..,..so..na+o-L,prr <br />