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s'I�Iliit7++�1'ai't� STATE OF GA[-tFORNIA Do not fill in <br /> THE RESOURCES AGENCY h' <br /> Filo with DWR DE=PARTMENT OF WATER RESOURCES No. 42534 <br /> ttce of Intent WATER WELL DRILLERS REPORT Stile well No <br /> 1 Permit No or Date �� of //��Othefe Nell No-S&— 121,L) -7 <br /> OWNER. .rame� v�..T {I2) WELL LOG Total depth= ft Depth of completed well-ft <br /> 17 L1 C7 <br /> Adt[is au from it to ft Forwatlon (Desenhe by color character size or material) <br /> (2) LQCATI 4F WELL (See fnYtntcttons) <br /> County Wees Well Number ^ <br /> Well address If different from above <br /> f <br /> Tasvnrhip —Range- - Sect[o <br /> Drdtanca from Atlas,xnads,raflmnds fences,e ' <br /> (3) TYPE OF WORK: <br /> New Well ❑ Deepcnrng ❑ <br /> Recoastnrction ❑ Ar— <br /> Recandltwntnpi ❑ <br /> Horizontal Wel! ❑ — <br /> Destrstettan DE (Dason'be <br /> destntctxrn r atenal2 <br /> procedures irr Ilam <br /> (4) PROPOSED — <br /> Domestic — <br /> Irngztlnn (� — <br /> ItHtustnal 0 <br /> Yell (] — <br /> St-a – <br /> Muarcfp <br /> }V$LL LOCATION SICETCfI Other ❑ — <br /> (S) EQUIPh(ENT (f!) GRA PACK <br /> Rotary [3 Reverse ❑ ❑ N' <br /> Size <br /> Na <br /> Cable ❑ Air 11r of bo — <br /> Othcr ❑ ]lacket 1] ra — <br /> (7) CASING INSTALLED o (8) l'EIWOHA St <br /> lana <br /> Of scee Steel ❑ Pp — <br /> Frotn Tom-- Dta G ge;6r FXCTo <br /> ft f In Wall f ft st <br /> (9) WELL SEAL, — <br /> Was surface slmtary seal provided? Yes ❑ No ❑ If yet, to depth,,, ft Were strata sealed agafnit pollution? Yes❑ No ❑ Infervat w!t <br /> hfethad of sealrn Work start I Complet Ira <br /> (10) WATER LEVELS WELL DRIL ER'S SniTE]v ENTT <br /> Depth of first water, if knowI'h(r well was drilled under mu iumniratiaa and ihls report is true to the best Of m6 <br /> Standintt level after swell t,ompletlft knowledge and eifej <br /> -(11) WELL TESTS SIGNt <br /> Was Nvell test mado? Yes 0 No ❑ If yea, by whoma y ' (We nlle <br /> Type of test Pump ❑ Bader❑ Air lift❑ NAM <br /> Depth to water -It sttirt of test-it At and of test ._ Ft { cis firm or co n:n) ( ed or pnwed) <br /> prscharse___—zgallmrn atter; boon Witer temperature Add <br /> Chemrcul analysis made? Yes C) Vo p If yes by whom? City z3P-17. <br /> ectnc lops mado? Yes ❑ No ❑ If Yes,nate"copy to this report Lrcease No ate of thls repo .2--.— <br /> 8a tnEV Z rs> 1F AbDlT1ONAL. SPACE IS NEEDED USE; NEXT CONSECUTIVEyLY NUMBERED FORM +seu sso 7 rasom cuno(DTosr <br />