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21907 :1 1211 <br /> 100 <br /> ORIGINAL s'pAL l <br /> I STATE OF CALIFORNIA 2 Do nOC jdl in <br /> THE RESOURCES AGENCY 4 S8 s I ^O <br /> File with DWR' DEPARTMENT OF WATER RESOURCES IfUU 1 1 <br /> f Nolis—f Intent Nn. ` WATER WELL DRILLERS REfp � <br /> Deal I'ennit Nn,or Uetr!Z.L,.��,�1�-/�� <br /> 7-LFt�ti��i,il�ll�'14L I n. <br /> f it <br /> (1) OWNU: Nan,...f,E�(?�(�1 elrLItr?_// of (12) WELL LOC: Total tkpit _ft.Depth of completed well ft. <br /> Address�..Q� t'fl�/1 from ft. to ft. Formation (Describe by vulur, character, sirr or materGl) _ <br /> - ",• City— J`7� Zip - <br /> s ' (2) l OCATI OF WELL (See ins(nletioms): s A <br /> �y,' Cuanty pwnrr's Well Number <br /> 1tu 4,1:- <br /> Well address if different(ro +a1><,vr_, r.V•KP N�PIYIC�n- Jl <br /> xu x <br /> Township 1l2ngr Sesi io <br /> 3 _ f <br /> Distance(n+n+citict,mads,railwads,fenrrs,etc- Jl[ !l fly rkd �id Fj <br /> ram (3) TYPE OF WORK: — <br /> 5f� aC �pa 5 New Well X Deepenine❑ <br /> Rem rmtmctinn f� •- `\ OV) <br /> Rca�rnditiuninR ❑ �� - \:✓, s} . <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials <br /> -- procedures in Item 11.( - •�'ti r �!- <br /> (4) PROPOSED FUSE: �. ��•.(� )) <br /> 2- Domestic ,•�{� % _�'_•� �. - •; <br /> Irrigation- <br /> Industrial `' ❑ 0 - <br /> { Tom Well ❑ <br /> -� Stock. - (�] � •~�� _ '\ <br /> O <br /> WELL LOCATION SKETCH \ Other Marlela�i I <br /> :res (5) EQUIPMENT: (B) CRAV�\i'ACTK: See <br /> jv^7 Rotary [l - Iteverse ❑ '"JK No❑ Slu' <br /> •:y Cable ❑- - Air {] Dlaerieter of bore - <br /> 01her %A( Due— ❑ Packed from - <br /> " (7) CASING IN ALLED: (81 PERFORATIONS - <br /> b a�,Zb rc. <br /> 't • Steel 0 Piastie 14 Cnra:rate n or r_L Type of per("tlonE seeeo - <br /> s; <br /> From To•'Z ,,Dia. GSges or FMtw,,, �= To f S1ot.� <br /> r ft. h.'. stn. Wall ft :`:= ft <br /> Y <br /> (9) WELL SEAL: _ <br /> +, tt'.s surface sanitary seal provided?. 1'rs'� No ei I(Yes,M depth_ ft. -- <br /> Were strata-sealed -against pollution? Ycs)d !tin ❑ ft. - - - - -- - �-� <br /> A(ethrxl.ol.seafia C �Vark_st2rtrd_ _ i5 C mPIeIN1 19 <br /> (a0) WATER LEVELS: WELL DRILLE•R'S TATEMENT: <br /> ,.+ 1)epeh_of Csrst ■ter,- i( known_ ��4 c ft ��� �[]G_-5 - --ft. Thi.eurf( hat drilfud Grufe my iurijef ct' and i 'r rrpn fi erne to the here.of my - <br /> r -.- • f Y.nnudewrte tln8 bf - <br /> y Standing level afler= <br />