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' STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WE L DRILLERS REPORT No, 374,025 <br /> ftatice of Intent Na J, 7 State Well Na rr <br /> Lacal Permit Na or Dat i i "� 2"- Other Well Na -- f <br /> (1) OWNER Name �` (12) WELL LOG Tgtal dept fr Completed dept ft <br /> Address :2:001 from ft to ft. Formation(Describe by color,character,size or material) <br /> Csiy ZIP <br /> (2) LO TIOYF WELL(See Instructions) r <br /> County w "Yl —Owners Well Number — <br /> Welladdress d dt�ffe t from above — <br /> Township f��7 Rang Section <br /> Distance from cities,road;railroads fences etc <br /> tr' <br /> (3) TYPE WORK — <br /> New Well Deepening ❑ <br /> Reconstruction ❑ '� r <br /> Recandltfoning ❑ <br /> Horizontal Well 0 f <br /> Destruction ❑ (Describe — <br /> destruction inatenals and pro- <br /> cedtires in Item 12) n <br /> (4) PROPOSED US f <br /> • Domestic <br /> Irrigation <br /> Industrial ❑ <br /> Test Well ❑ <br /> Munfcr VV ❑ — O <br /> O er <br /> WELL LOC:ATIUN SKIRTCH ibe) <br /> (5) I?QUIPME j CRA C% <br /> ftotuy,yr Reverse Q 1 No <br /> Cable ❑ Air ❑ ` r• t of bare <br /> Other ❑ suck rom ` t <br /> (7) CASING INSTALLED. (8} PEft 4 TI <br /> Steel ❑ Plastte T of orslzooF <br /> From T t Gags or <br /> ft f I Wall i size <br /> (9) WELL SEALf �n -- <br /> Was surface samtary seal provided? Yes 3�F No ❑ tf yes,to depth/Aa._,-__ It — <br /> WerestrataSealed agains llulw /es ❑No f f It <br /> MsOd°Isealiag $ Work started ---- 19— Complet 1S� <br /> (10) WATER LEVELS WELL DRILLER'S STA T <br /> Depth offlrstwater iFkoawn fL This well was n!! under m rd{ciian and this report is !rile to the <br /> Siandmg level after well completion ft best of my kna nd-be! <br /> (11) WELL TESTS <br /> Signed <br /> Was well test made? Yes ❑ N If yrs,by whom?0 <br /> ypo otest ]PUMP 11 Bailer [I Air lilt El NAME GrO <br /> epth-f <br /> o wat er at start of test it At Und of test ft, rpotion)( or nted) <br /> Discharge gal/mn after Address a <br /> mp <br /> Chemical analysis made? Yes fa No❑ If ye;by whom? City ZIP <br /> Was electric togmade Yes [I Nn ❑ Ii X5 attach copy tothis rt LieenseNa Dateoft1wreport <br /> GWR ]Be tREy 12-4861 IF ADDITIONAL SPACE IS NEEDED USE Nei CT C0NSVCUTWE4Y NUMBERED FORM 96 96333 <br />