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QUADRUP tCATE STATE OF CALIFORNIA DO not� fill in" <br /> VSA®�Celt1(D�/W�fE1 7H£ RESOURCES AGENCY oo AA ff <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 2480�9 <br /> Notice of Intent No. WATER WELL DRILLERS REPORT <br /> State Well No, <br /> L83-1139ocal Permit No. or Date ' <br /> �^ �n gOtthye�r Well No. <br /> (1) OWNER:r Nam /� : c 'LIVE} try P 0 D1jC; 5;11k1G (12) WELL LOG: Total depth' i:T ft. Depth of completed well�ft. <br /> Address k+ O (F`OODP '�+O . 147EMN.tt•[d�c.,L+04' .i.NG. # from ft. to It.. Formationn��,(Describe by color, character, size or material) <br /> City .i< <*. V 1 G SAI JLt[.E Zip9 i-5 3� 0 - 4 �b - SiD�:l <br /> .(2)- L0,CAT1 N OF,WELL (See instructions): q� Gra- vel <br /> County urn Owner's Well Number 'p,� + - # c f <br /> Weil address ifdifferentfrom above Patterson 'ass . { - 20 <br /> Township Tim cy ,_,_Rang Sectio 2 - 3 -- ._. -- .e. <br /> Distance from cities, roads,railroads fences,etc So w i - eve <br /> nl <br /> east 61de 25 - 1-1'- {} <br /> I �� - �� - 1. V 1 k Sand <br /> �1�,[j� - _ <br /> (3) TYPE OF WORK: l <br /> New Well Deepening lit <br /> _ 118 \)Sand <br /> ciayTaaq <br /> e <br /> Reconstruction D 31 _ '., ,. <br /> Reconditioning ❑ -t ... - _ '41+ <br /> , .,+.... - Shale <br /> Horizontal Well ❑ _ 4 '* s3i7 <br /> Destruction ❑ (Describe _ I �.;�. <br /> destruction materials and <br /> procedures in Item 12)< 165 - o S&nd <br /> (4) PROPOSED USE: 170 A76 Css <br /> Domestic d 1,76. -4` <br /> Irrigation `� ❑� y n <br /> Industrial 22L JqnM <br /> t <br />` Teft Well �:i �' <<� a 3y y� kX gg� Lsla <br />`} Stock r•\ _�. - •�,. ., .. <br /> j - •. �" Municipal"j, ❑'`` 3 10„. -- t_,.- E.iS:E Ft Gravel Set .,Up <br /> WELL LOCATION SKETCH '-0thert Q <br />+ (5) EQUIPMENT: f(6) GRAVEI:"PACK: Sand <br /> j <� <br /> I Rotary Reverse ❑ t Yes` No ©f Size w <br /> 415 <br /> �f- <br /> Cable El Air ❑ ,D'�meter of bore .�'� r( - _-' r.l`�_. 9G. 3 <br /> Other ❑ Bucket S <br /> and <br /> C3 P, <br /> ' S <br /> l (7) CASINGINSTALLED:' , (R) I'ERFORAIiI(fIi[S.: - , & Shale <br /> 4 <br /> Steelz Plastic ❑ Corritq to j, Type of perf�4” or fie of screens - <br /> From ToI,PM,•iia. Ga$e of Fm3u d:�%To w<y$1�CZ'� 6 — G <br /> ft. ft.s An. Wall ft` ft. �-: <br /> I - <br /> (9) WELL SEAL: `Was surface sanitary seal provided? Yes No ❑ If yes, to depth_L---ft. - <br /> t Were strata sealed against pollution? Yes I_] No [] <br /> Method of sea' + Work start 19 Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known R• This well was drilled under my furisdiction and this report is true to the best of my <br /> iStanding level after well completio g, knowledge and belief. <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No 0 If yes, by whom? (Well Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME I 11,11NINGS, BROS . !y <br /> CO <br /> Depth to water at start of test ft. At end of test ftPerson, firm,or corporation)rporation) (Typed or printed) � <br /> Discharge gal/min after- hours Water temperature Address_3 525PRIftMA R+ AVE,_ - <br /> Chemical analysis made? Yes L] No El If--yes, by whom? City LODMI0.1, CA <br /> Was electric Iog made? Yes 0 No C1 If yes, attach copy to this report License No. ate of this report $ <br /> E, DWR 168 IRM 7-76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I // <br />