Laserfiche WebLink
.1 Y <br /> ' STATE 00 CAUFOITMA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill -in <br /> File with DWR DEPARTMgNT OF WATER RESOURC>=S <br /> WATER WELL DRULLERS REPORT N0. 384501 <br /> Notice of Intent No State Wali Na <br /> Local Permit Na or Date <br /> (1) OWNER Name va (12) ✓WELL LOG. Total depth ft.Completed depth ft. <br /> Address from ft to ft Formation(Describe by color,character,size or matenal) <br /> city a zip <br /> (2) LOCATION F WELL (See Instructions) <br /> Countyt7 Owner s Well Number — <br /> Well addrms tf different om above s <br /> Township—C&e&At&,,^Range ' ecdan - 7� B A <br /> Vistafrom cihes,roads,railroads,£euces,eta AID O <br /> — f J <br /> f'Y 2 tf' <br /> (3) TYPE OF WORK. <br /> New Well �L Deepening ❑ <br /> Reconstruction ❑ — el <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe — <br /> destruction matenals and pro. <br /> cedures In Item 12) <br /> (4) PROPOSED US _ <br /> Domestic _ <br /> Irrigation \ <br /> Industrial ❑ _ <br /> Test WeII <br /> Mnnici ❑ _ <br /> a - <br /> WELL LOCATION SK=H �) <br /> (S) EQUIPMENT CRAY Ci: — <br /> Rwary Reverse ❑ No 12 <br /> Cable ❑ Aar 1 <br /> ❑ � is et of here <br /> Other ❑ g goal �} — <br /> (T)CASING INSTALLED- (8)My OHATI _ <br /> Steel ❑ PlaslEa ❑ ret T oI \1 orsimnf Q _ <br /> From T �Di Gage ort <br /> ft f t Wall VNI size <br /> bo — <br /> (9) WELL SEAL <br /> Was surface sanitaryseal pvonded2 Yes qL No ❑ If yes,todepthjQ-Q_it. — <br /> Werestrata sesaled agatost pollulton? Yea ❑ ❑ interval ft. _ <br /> Method of sealing { Work started 1 CompIcted 1S <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT' <br /> Depth of first water,if known ft. <br /> Standing levelafterwelleamplettmThis well was drilled under m ftsrfsdicaon and this report is true to the <br /> ft <br /> best of my knosaied e d KIZI <br /> (11) WELL . St ed <br /> Wu svcil test made? STSNo ❑ If yerti by whom? (WORD <br /> er) <br /> Type of test Pump ❑ Bader ❑ Airlift ❑ NAME <br /> Depth to water atstart of test ft. At end of test ft (Pe firm rpoS?tign) ped or printed) <br /> • Ducharge gal/minofker hours t rtemperaiure Address -- <br /> Chemlcalsnalyafs mada2 es ❑ No❑ If ye;by whom? City- `�� <br /> a Yes ❑ No ❑ If yes,attach ropy to thisreport I.feense No( '� Pati of this repor — <br /> 13WR 388 IRAN iy,aa) IF ADOMONAL SPACE IS NEISMID USE NEXT CONSECUTIVELY NUMBERED FORM <br /> eb 96353 <br />