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hs) t <br /> ORIGINAL STATE OF CALIFORNIA DO not fill Itl <br /> a(�fi_ THE RESOURCES AGENCY <br /> y' No. 094105 <br /> . : File with DWR DEPARTMENT OF WATER RESOURCES <br /> I <br /> k Norica of Intent Nn./ WATER WELL DRILLERS REPORT state Well Ne <br /> other well No. <br /> i"({t Local Permit No.or Date <br /> L`... <br /> N (12) WELL LOG: Total depDepth of co.npl«d.els <br /> OWNER: ame R. <br /> from ft. to h. Fn ntlnn (DeferiM by —[or, c ter, tis t or ma rid) <br /> City ZIP - <br /> E11tr," (2) LO ATI O WELL (See instructioru): _ <br /> >� town O.•ner't well Number <br /> \Veli addrea it di ent fr above <br /> 4 N:�.,.... ang. e ti <br /> "r Tuwnthip a <br /> Dittane.f cities i,railroads,fe ces,Me. _ <br /> w <br /> t (3) TYPE OF WORK: <br /> t ' ' t New Well DeePeninq ❑ <br /> Remndltioning ❑ "I� <br /> }fodzontai <br /> Well ❑ 't - <br /> Destruction ❑ (Describe _ <br /> destruction materialts <br /> procedure In Item <br /> (4) PROPOSED - <br /> Domestic <br /> y <br /> Irrigation <br /> i Ys <br /> Industrial ❑ <br /> 4Af l ht \ ❑ _ <br /> •{ Well <br /> qg r Q,�¢� Municip <br /> Othr ❑ <br /> LL•LOCATIOV SKETCH <br /> e <br /> 111 (6) GRAN <br /> A (S) EQUIPMENT: <br /> I ary ❑ Aevene Q ❑ No Site <br /> Rot <br /> Cable �JI <br /> - Ai. ❑ r of L�e — <br /> mr Other ❑ Bucket ❑ oro t <br /> 17) CASING INSTALLEDr( (G) EHFORA <br /> PLttic <br /> Co Te of pe or a of scree <br /> Steel ❑ Type _ <br /> r" <br /> From To Dia. Wall 1 ft EG <br /> y: d�tA ft, ft. n. _ <br /> 4 <br /> i (g) WELL SEAL: _ 1 D <br /> +1; Was surface sanitary seal provided? Yes ❑ \ If y <br /> o '$ yes. to deC,hIt. - <br /> ' ❑ Interval ft. <br /> fy t' Wert+ strata ceded against pollution? eXX <br /> ❑ Vo Wnrlt started 19 Compkt 19 <br /> mit ° Method of 'calls' WELL DRILLER'S STNTEMENT: <br /> 'rose to the beN o/ my <br /> fit. <br /> (10) WATER LEVELS: This .,,,Ias! wdrilkd --d—r �V i—Win ctloand this rcpon <br /> — <br /> �•, Depth of first Water,.if ktso _ft. knnwledac heliel• ,!'7q <br /> Stand level aher ell tom Pleno D SICKED (W<u D LI <br /> (11) WELL TESTS: hoe? <br /> \ \Vu r•e 11 test made' Yes Nn [] I! sec, by <br /> Pump Bailer❑ Air lift ❑ NATE or ri <br /> TYpe of test k croon, firm r cnrporati IT <br /> Dept ►et Stan of tat___(-4—it. At end of test <br /> s Address <br /> is ��-!�al/min alter hnun \Vater temperature city LP <br /> a,l a e <br /> �i,14) �•. Ni/1 if .es. by whom?-- �J ate of this"Irt- <br /> ' •a Chemical analy+u made.s Ya ❑ o/ License Nn.�'1- <br /> r Nn II sn, nnaeh copy w this report <br /> ,ro 'Vas eiearic ha rnade? Ya l7 <br /> DWR tee taw 7.761 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> Y <br /> t.. <br /> r�rt y yr �f: <br /> 14-+w$:{lI�tY4' .tr''f{ri. M'•w. .!fl'T'n/,1h <br />