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1'0RIG[NPiL STATE OF CALIFORNIA Do not fill 1]2 <br /> THE RE=SOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 45025 <br /> Aftice of Intent O WATER WELL DRILLERS REPORT state Well No <br /> al Fcrrmt No or Date Other Well No.= 'tIS <br /> {1 WNEIi Nora (12) WELD. LOG. Total depth!f V ft Depth of completed weiLmait <br /> Addres from ft to ft Formation (Doesor,be by color character, size or matemal) <br /> Cli in ) <br /> (2) LCATI NOF-WELL (See Instrucbnns) - _ <br /> County Owner's Well Number <br /> FYWell address if different from abo 910 - <br /> Towitship Range Rectio f f I <br /> Dasttace from etdes,roads,railroads,fences,etc <br /> w <br /> (3) TYPE OF WORK <br /> pC'011H,q Hen Well i Deegenfng CI �j'~^ a A .1. - e <br /> L"41 .Reconstruction [3e1 < <br /> nReconditioning ❑ - <br /> G/ Horizontal Well ❑ � \ - <br /> Destntction f] (Deacribo - <br /> destruchon materials d <br /> procedure-,In Item -- <br /> (9) PRorOSED — IN <br /> Domestic <br /> Irrigation <br /> Industrral ❑ <br /> t}Veil Q <br /> S .- <br /> Mrmip <br /> WELL LOCATION SKETCH N\A Other E7 <br /> (5) EQUIPME'VT (B) GRA F PACU: <br /> Itatary [] Reverse © 0 No Seto <br /> Cable ( Air 0 ter of bore <br /> Other 13 Bucket 0 ra 1 <br /> (7) CASING 114STAL1E33 (R ERFORR <br /> Sleet , Plastic[] C Type of po n n ae of aerie <br /> From T Din r R To �S - <br /> ft [ In Wall f ft s — <br /> (9) WELL SEAL. — <br /> Was surface sanitary seal provided? Yes (8 No f_I If yes to depth_'!M ' <br /> Were strata sealed against pollubuna? Yes❑ No [3 Interval _ft <br /> Method of geallop }York starte 1-9= Complete 19 <br /> (10) WATER LEVELSf t WELL DRILLER'S STATEMENT <br /> Depth of fast water, )f kno� ft, This well taut drilled ander mY jurisdiction and this report is true to fhe best of nil <br /> Standing level after well completlo Z)Qft knowledge an lei�.y� 1 <br /> (11) WELL. TESTS Sic; ��ZG�L�.L��L]1LLi �V�� — <br /> Was Well tett made? Yes E7 No Cl if yes, by Nvham' (}Nell Driller) r <br /> Type of test pump 13 Bailer Ej Atr hft ❑ NAM 1 -�- <br /> Depth to water at start of test, it At end of test.-It ,or earporatfou) ('ryp r ph ted <br /> t <br /> llfscharge _,.al/man ails*_ihhtrrstJ 11'4 <br /> Water temporntur Address <br /> Chemfoal analyses made? Yes ❑ No ❑ If res, by wbom? CA P <br /> }ictnc log rondo? Yes C] No 0 If Yes, attach copy to this report License No to of this repo <br /> - fib (ttev >-761 IF ADt)IT10NAI.:SPACE IS NEEDED USE NEXT CONSECUTIVEI-Y NUMBERED FORM s3ri4-s107.7v1oXQUA00�raaer <br /> t til <br />