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- ----- ------- --------- <br /> 1 STATE OF CALIFORNIA <br /> ORIGINAL (��]\ THE RESOURCES AGENCY Do not fill in <br /> File With DWR DEPARTMENT OF WATER'RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 358396 <br /> Notice of Intent No. State Well No. <br /> Local Permit No.or Date Other Well No. <br /> (1) OWNER: Name / 12,2C (12) WELL LOG: Total depth 4242 ft-Completed depth 1 ft. <br /> Address from ft. to ft. Formation(Describe by color,character,size or material) <br /> City ZIP _ � �� <br /> (2) LOCATION OF WELL (See instructions): _ <br /> County Owner's Well Number _ ✓ <br /> Well address if different from above ! .. — <br /> Township Range Section — j c— t <br /> Distance from cities,roads,railroads,fences,etc. 3 — <br /> _ 1 � <br /> (3) TYPE OF WORK: — +� <br /> New Well Ip Deepening ❑ — <br /> Reconstruction ❑ — Yt <br /> Reconditioning Q _ <br /> Horizontal Well ❑ — 4 <br /> Destruction ❑ (Describe — <br /> destruction materials and pro- <br /> ?' <br /> cedures in Item 12) <br /> (4) PROPOSED USE: , rr ./ CV <br /> s� <br /> Domestic <br /> Irrigation ❑ <br /> p7' -� n • T <br /> Industrial ❑ - _, <br /> Test Well ❑ _ - i; <br /> Municipal\ j ❑ 4;5 l <br /> Other 0. —.• "54 ,72 <br /> WELL LOCATION SKETCH ��ju(tbe\� <br /> (5) EQUIPMENT: I CRAM j F•ACK: <br /> Rotary ❑ Reverse ❑ l Y NooV�J /JS' �� 7 <br /> Cable Bf Air ❑ \ t�� tt?of bore ` ��� <br /> Other ❑ Buck e Packed Trom <br /> (7) CASING INSTALLED (8) PER I(ATIO� `• _ <br /> Steel Plastic ❑ aerate,❑ Typ�of rsize of — <br /> To i Gage orWI— <br /> Fromofft. ft, i Wall � �t� size _ <br /> (9) WELL SEAL: _Was surface sanitary seal provided? Yes No ❑ If yes,to depth ft. <br /> Were strata scaled against pollution? Yes ❑ No Cl Interval ft _ <br /> Method of sealing Work started 19 Completed 19 <br /> (10) WATER LEVELS: _ WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known l y SS _ ft <br /> Standing level after well completion ! �2- �i ft This well was drilled under,m jurisdiction and this report is true to the <br /> best of my knowledge and beliel. <br /> (11) WELL TESTS: Signed <br /> Was well lest made? Yes ❑ No ❑ if yes,by whom? (Well Driller) <br /> Type of test Pump ❑ Railer ❑ Air lift ❑ NAME <br /> Depth to water at start of test ft. At end of test R (Person,firm,or corporation)(Typed or printed) . <br /> Discharge gal/min after hours Water temperature Address <br /> Chemical analysis made? Yes 0 No 0 If yes,by whom? City ZIP <br />