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q. ORIGINAL�HL .STATE OK CALIFORNIA i: Do not fill in <br /> THE RESOURCES AGENCY p� e�r� <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 2 2 618 <br /> Notice of Intent No. WATER WELL DRILLERS 1,REPORT state Well No. <br /> Lc ormit No.or Date (o � I <br /> {?r^ Other Well No. �. a <br /> rf <br /> (1QWNF Natne w Qom` ++ 'e (12) WELL LOG: 'Total ilePthAM,Depth of completed we1mft. k <br /> I <br /> Address. a3. A 1, <br /> l from ft. to k. Formation (Describe by color, choracter, size nr materinl) <br /> y 'Lip j <br /> (2) LOJPATIONf OF WELL, (See instnictions): ' <br /> County _ Owner's Well Number <br /> Well address if tliffezcnt from obo e <br /> Township Rang Sectio <br /> Distance from cities,roods,railroads,fences,etc <br /> r — 3 <br /> i <br /> (3) TYPE O WORK: <br /> l <br /> New Wall Deepening 0 <br /> ' Reconstruction _ <br /> l Reconditioning [� <br /> Horizontal Well ❑ <br /> Destruction❑ (Describe <br /> destruction materials d <br /> procedures frt Item _ <br /> NAau�t (4) PROPOSED <br /> �j- Domestic `T <br /> Irrigatio <br /> Industrial ❑ �' t <br /> W eA l swell ❑ _�• <br /> s 'A!2 o <br /> MunEci <br /> WELL LOCATION SKETCH Other 0 � <br /> ❑ <br /> (S) BQUIPhIENT: V (6) GRA lk"k PACK; <br /> Rotary I Reverse ❑ �No Size 1 <br /> Cable 0 AirZ f <br /> ❑�, ar of bom.�� <br /> Other13 <br /> Bucket L3 ro \ <br /> — S <br /> (7) CASING INSTALTD <br /> Steel❑ Plastic EBS/C Vt Type of p i ze of sere <br /> From T Dfa. g r F0 To — <br /> l <br /> ft. <br /> f. > n. Wall ft <br /> (9) `vEL'L. SEAL: <br /> Was surfs <br /> _ <br /> Wa co sanitary aertl provided? Yes�,,�No❑ I(yes, to depth. _ I� <br /> Were strata sealed against ollitio` yes No 0 Intervat __ft- <br /> Method of senting - P Work started " 19 Completed „_Ig <br /> (10) 'NATER LEVELS: . <br /> WELL DRILLW STATEMENT: <br /> t <br /> Depth of brat venter. if know <br /> ft This epeR toredo, ade my iurfsdiction n this report i7 rare to the best of my <br /> Standing level after well completion __ft. knosuledge a(I1) WELL TESTS: SIGN I' <br /> Was wail test madO Yes ❑ No [elf yes, by whom? rMer } <br /> Type of test Pump ❑ Hailer 0 Air lift❑ NAM v <br /> Depth to water at start of test fL At end of test__.._.__ft Petsgn�Ste} os t_arporatit7n) (T ed r p a1) <br /> Discharge gal/rain :after hours Water temperature Addr <br /> eaI analysis made? Yes ❑ No P"_If yes, by whom? <br /> eetde log made? Yes ❑J No[ /If yes,attach copy to this report License No _3La I m�_.� . _ nate aF this repo r <br /> owR <br /> 166 tREV.7.7al IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 47ua gra 7.79 SOM po0.DQi r par <br />