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fr <br /> t <br /> r I ,c+TE OP CAUPORNIA <br /> THE F'E IOURCES AGENCY Do not fill In <br /> ORIGINAL OFIPARTMEI`• ' OF WATER RESOURCES <br /> G{ File. with DWR WATER WELT DRILLERS REPORT y0• 257288 <br /> State Well Na <br /> Notice of Intent Na .-- <br /> Lxol?emit Na or Da¢ 8 9- if-7 G- other Well Na. <br /> /1) OW24ER: Name�HEV� :4 INC (12) WELL LOC: Total dept L' it.Completed depth 2it <br /> Address2q f d CAF1 iN0 g 4 MO N ,_ from it. to ft Formation(Describe by mice.character,if=or trlaterlal) I <br /> City 64AJ 4M�n/ -! C'q ---zip X4583 p aaK <br /> (2) LOCAT:O,N OF WELL(See instrticticns): vY7wu <br /> < �/ S; sAA e. iLtw 9q.. t rotOu . <br /> County/9� o'444fN Owners tycll NumLer 57- (U )OvotJIs <br /> 288B+r.KHis 1ti R ArvTA G4XP2 u w tw- 6v <br /> Well ad&,ss if different from abov� z _ 25 C �os-d erowN <br /> Township TZ S Range 6 e an:•ion s•IOW N <br /> Distarlec from cities rwda raibwdy,fen�a.et <br /> 2S - <br /> SOON �ti -C��A' $6 5; e. - <br /> b Siwe <br /> t <br /> .3) TYPE OF WORK: <br /> New Well M.Deepening ❑ <br /> RMVmtruChOn ❑ <br /> ♦ R <br /> econditioning <br /> ❑ = <br /> /-D a A. Horizontal Well ❑ _ <br /> / Flu EL Destruction ❑ (Describe <br /> Y •,r,E�h 1 hj�'L• datmctior.materials and pro <br /> cedures in Item 12) <br /> wrJ (4) PROPOSED US <br /> Domestic <br /> �r 3• Inigation - <br /> Indarial ❑ - <br /> r ys — �Q 41j Test zll ❑ __ <br /> _ Y Munici 1 ❑ - <br /> O er)K t OR <br /> WF1L LOCATION'Sr.ETCH <br /> (!) EQUIPIAMT., CR CX: <br /> Rod?❑ Rr ❑ Yf`ry No 1 v. <br /> Gde ❑ Air ❑ 1�;�s�eTtesrn(bere�$_ ZS <br /> }fI0 699Dther Buck V rom <br /> (T)GSING INSrAW3D. is) PER <br /> Sted ❑ Pisair pI. ry d ons she,of <br /> From T i Cage or t <br /> size <br /> K A0 3 wL.0 3 0.020 _ <br /> Y iC <br /> - I - <br /> (9) WELL SEAL: <br /> wdwrfsmmNtsry»ilpmided7 YEXI No[] ll Yeatodepth Z•S fe <br /> Were RndraladfjWac Bursa? Ya C N.A lntersvl fL - 4 <br /> ,l• Ip640 ��� •w� ca'"'^�d+." Wu Work sturted IO O 19 Com leted 19 '. <br /> Meihad d rAlirl{ <br /> -(10) WATER-LEVELS: WELL DRILLERS STATEMENT: # <br /> DeIXAd tlrR wtw.Il knesnl <br /> it <br /> S� IL Thi, wetl um viedge undo mqq JunLdlcNon and this Y rrr.e lfl��,�E/ <br /> Sai diogk.d dler.eR inurortan Lest of my knorufrdgt and belle. �n/J'_ C Fvt, <br /> (11) WELL TESTS: Ffi F_.N G• (AJC Signed We Dn ler) ... <br /> Was Yefl tee asd.? Yes No 13 Rya lw rhom7 �j PEGI•-2u+'1 i^kiGo 94-r/Ori GV-- <br /> TypdeM pum¢Q.� Boiler X Ai glt L NAME pywn rrq.� eyr¢o�+yon <br /> rxgh.ro. en `� t At enddlal_S��;� fL Z�i ZS IG •R 1'I fir' f(.7 C,)Tr�sJ� ) <br /> pyeM�� dinaftr be. N•ele.�gmsrrrur Address Z , <br /> �— F+IiGE L 3 City �j•iCCC T'O IJ Cil ZIP � O <br /> j Ckmv+l.n.lyn.m s! Ya 21` Nn❑ Hre.br�iw�.,t - Jr)Z Z Date of ehb revert l0 1 <br /> w Nende lg{ de Y. No fR Ifye.allauh mpr lolh0 rea'++ License Na <br /> le A Orr10NAL SPACE IS NEEDED. USE NEXT CONSECVTVlLY NUMBERED FORM Y Mlfl <br /> owl, Ita IRN. fII•M <br /> �I <br />