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QUADRUPLICATE <br /> Use to comply with STATE OF CALIFORNIA <br /> local l'ey„irement5 THE RESOURCES AGENCY DO not fill in <br /> Notice of intent No. DEPARTMENT OF WATERRESOURCES No. 083137 <br /> -Tp WATER WELL DRILLERS REPORT <br /> Local Permit No. or Dat RD" /!f 7 stale Well No. <br /> (I) OWNER: Nam <br /> Other Well No._ _ <br /> Pjar He <br /> Ad 16404 S. NO R Pon (12) WELL LOG: Tnlal daPm l Ql. Depth of completed we)1 - <br /> from ft. to ft. Formation (Describe b t <br /> CifY ( Pte• • O Y color, character, size nr matednl) <br /> Zip - 22 Sand <br /> (2) L ATIpp]N�j Ojg`�W <br /> Gouty Soman Jo$QIl ELL (See iZ."" tiotu): 22 CIe & Sand streaks <br /> OwneJx {Yell Number - S+ <br /> Well address if dilleren[from above _ ne S p" <br /> Township 77 & a ayv <br /> Rang Sectio a <br /> Distnnce!mm cities, roads, railroads,fences, t 2. E Donahue <br /> mi Iflest of"North Ri on Rd. - <br /> north side - <br /> (3) TYPEOFWORK: <br /> Naw Well g Deepening ❑ <br /> Aecomatmction ❑ _ <br /> Reconditioning ❑ _ <br /> Horizontal Well ❑ _ <br /> Destrugiom ❑ (D.wd <br /> destnwtiom materials v\ <br /> Procedures in Item _ <br /> (4) PROPOSED n1 <br /> Domestic N <br /> Irrigation O ❑ <br /> Industrihl ❑ <br /> T r Well ❑ <br /> St c U <br /> Mum'F _ <br /> WELL LOCATION SKETCH Other ❑ _ <br /> (5) EQUIPMENT: (D) GRAY ACK: O _ <br /> Rota' IR Reverse ❑ No <br /> Si. <br /> Cable ❑ Air ❑ r of bore 1 _ <br /> Other ❑ Aucket ❑ mm _ <br /> t <br /> (7) CASING INSTALLED: <br /> (S) PER ORA L _ <br /> steel ❑ Plastic Co a Type of Pe or'ze Of scree _ <br /> From To Dia. G� r F To - <br /> Wall ft. ft. _ <br /> (9) WELL SEAL: _ <br /> Was surface sanitary seal provided? Yes X No ❑ If yes, to depth_lt. _ <br /> Were strata scaled against pollution? Yea ❑ No ❑ hdervai <br /> t _ <br /> hleNad of sea' <br /> Work start 19 Completed 19_ <br /> Dept w <br /> WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if knor _ <br /> f0. This Well rocs drilled under my jurisdiction and this report is (nee to the best of my <br /> Standing level after well completio knowledge and belief. <br /> (11) WELL TESTS: 1 <br /> Was well test made? Yes SIGNED � Dr; <br /> Type of cast ❑ NO If Yes. by whom? - Inc, <br /> Pump ❑ �ItRailer H os ell Drilling CQ <br /> Depth to water at start of test ❑ At end frrtwrftt ❑ rt NAME-ti® ngS Br N t <br /> (Person, firm, m rnMmatmn) (Typed or Printed) <br /> Discharge_ gal/mm after hams Water tem Address <br /> Chemical analysis made? Yes ❑ No If � � r-. IV <br /> yes, by wh [' I Citl Zip <br /> Was electric log made? Yes ❑ No If vas, attach ryF ep <br /> PY.fO report License ly' . Date of this repo <br /> o 9-11-80 <br /> DWR IBD (REV.>.>61 IF ADDITIONAL SPACE t4A41EEDFeR,1t %E)NL *,,MiFONSECUTIVELY NUMBERED FORM <br />\ <br /> GAN VJJOAQI.UiN LOCAL <br /> HEALTH DISTRICT <br />