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STATE OF CAUFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> rile With DWR DEPARTMENT OF WATER RESOIi .SES J <br /> t <br /> NVATER WELL PtRILLERS REPORT N0. 306518 <br /> Notice of Intent No. ,_ Stale Well No <br /> Lacal P-rrn4 No.or Date Other Well No <br /> a, (1) OWNER: Name (Z n" c�% 'L,LQ (12) WELL LOC: Total depth�4. R.completed depth ft. <br /> n Address_C1LL1:LL- from R. to I. Formation(Describe by color,character.size or material) <br /> I City- �I�1VfS 41i� ZIP <br /> 7n a <br /> U 1 — <br /> (2) LOCITION OF WELL( ee insh•uctions): <br /> County� _Owner's Well Number — <br /> C` <br /> Well add r <if different fSom above - — <br /> Towr III Range `Section �(f <br /> _ <br /> Distance-from cities,loads,railroads,fences,etc. — <br /> t3) TYPE OF WORK: <br /> New Well 9�• 4 epening 0 <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> a� Horizontal Well ❑ __� <br /> Deslnlctlon ❑ (Describe <br /> destruction rlaterials and pro- <br /> cedures in Item 12) <br /> ty (4) PROPO°ED US <br /> Domestic _ <br /> Irrigation <br /> i' Industrial ! ❑ _ <br /> Test Well �\� ❑ C� <br /> btunici,� I ❑ _ <br /> WELL L ATIO"' SKETCH <br /> (S) EQUIPMENT: CRAY CK <br /> Rotary/?_ Reverse ❑ 1 Nn is <br /> Cable ❑ Air ❑ et f bxe� <br /> Other ❑ Buck• from <br /> (7) CASING INSTALLED. (8) PER k r1 _ <br /> Stet) LA-- PL oic Eln� Ty of fa 'on or size of r Q — <br /> From I T Di Cage or I t — <br /> ft. f I Wall — <br /> // J - <br /> f <br /> ' (9) WELL SEAL: _ <br /> Was surface tanitiry seal provided? Y, FA--No ❑ If y,s,to depth 02G ft. — <br /> Werestratasealedagaimtpollution? Yes ❑ -�No P' Imemal <br /> !.lethod of sealing1 L!�- Work started 19 � Completed to <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> er <br /> Depth of first wat ,if known `�O ' ft. <br /> This well drilled under my jurisdiction and this report U true to the <br /> Standing level after well conpkv ion �— ft Ixsf nJmy amledg4,n� l J ' <br /> (11) WELL TESTS: Sinned <br /> Wit well test made? Yes ❑ No If yes,by wi.., _ Well nller) <br /> Type of test Pump ElBaticr ❑ Airlift ❑ tit\!.tt•. <br /> Depth to waterat start,[test___`t. At end of test —ft. IPnspn,h rat m) ypedw pnntedl <br /> Ducharv, galimin.af•er, _—— Water temperature Address <br /> Cheminl analysis made? Yes ❑ N.aVF If yea,by whom? _ r�ity ZIP <br /> was electric ksg made Yo ❑ Nn •—'If vel attach:+•nv n, hn nrywr _ License Nu.— Date of this report <br /> IF ADDITIONAL SPACE IS NEEDED_USE NEXT CONSECUTIVELY NUMBERED FORM b -.333 <br /> DWR 186 IREV. 12-SM <br />