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C ORi64'l AL STATE OP CALIFORNIA Do not fell in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 42535 <br /> Diohce of Intent Nn WATER WELL DRILLERS REPORT <br /> 5tnte Nell No <br /> 1 Permit Diu or Date: <br /> ---� � ',. Other Nell No � t <br /> OWNER ham d�-. (12) WELL LOG Total depth� Depth of completed welLawit <br /> Address- from it to It Formation (Describe by color cbvncter, size or material) <br /> City— tt p - <br /> (2) LOCATIOa OF WELL (Seeinstructians) J R) <br /> County e1�R� - V 1 VN—Owners Well Number <br /> Well address if different from avc <br /> j � <br /> Townsbtp Range Sectio f/ r Le t M", <br /> Distance from cities roads,rulroads fences,etc - <br /> r <br /> (3) TYPE OF WORK <br /> Ne,v Well;&,Decpening 0 G <br /> ,Reconstruction [) <br /> f3eCoxrdrlraeing [] - <br /> l]oruontal Well 0 � <br /> Destruction C) (Describe <br /> destruction matatsnls <br /> Procedures ua Item <br /> (4) PROPOSED ZI 4 — t <br /> Dames tic. <br /> VAN <br /> Indusus - <br /> Icltaan � <br /> I <br /> - <br /> tnzf ❑ <br /> d 4VeQ <br /> hfunacfp - <br /> `YELL LOCATION SKETCHOther Q © - rp, <br /> (5) XQUIPUFNT (B) CRAVES PACK - <br /> notiry © neverse [310 No PrI Su o <br /> Cahle' D4 Air © v. er of bora <br /> Other El Bucket Q crt+ro <br /> (7) CA5INC INSTALLED (8) PBItFORA lX 5s - 70 <br /> Steel D( Plastic E] Co a to 'type of 1) �n or of scree - v <br /> I'raln To Dia I Ca r F TO I — <br /> ft ft st <br /> (9) WELL SEAL: — <br /> Was surface sautlary seri)provided? Yes 0 No If yes, to depth ft <br /> Were strata scaled against pollution? Yes ❑ No�x Interml—ft aaa - <br /> Method of sealln Worst start I@ Comple cJ <br /> (10) WATim LEVELSr s WELL DRILL ER'S STATEMENT <br /> Depth of first wLiter, If know This Well WRs drilled under m <br /> Standing Pavel after well eompletio � [t knowledge o beeliigi � ltrrEsdtcrfon and ihty tepert is true to the best of mp <br /> (11) WELL TESTS Ssc�-. es�Et .f -&VILA I'A 9 0^1--� <br /> Was well test mndeo Yes ( NO[] II yes by whom?�, [ {Wi1�Driller) <br /> Type of test Pomp Ha,]er❑ Axl lift❑ Nt�M� # 10 1 <br /> Depth to water at start of tet'L_L^-ft. At end of test W 6 {P Arm, or eq -r�ahon)jjyped or printed) - <br /> Discharge g�]/rota nFtrr ,_,-,hours Nater tcmpenture <br /> Addres� �^ 4 t? <br /> f �j- <br /> Cheameal analysis made? Yes 0 rio If yes, by whom? Z.Rx <br /> ]ectne log made? Yes [] No IE yes nttoch capy to thas report License lvo -` + � Dnto of this xepnx <br /> 188 IREv tee) 1i'ADDITIONAL SPACE 1S NEEVI✓D USE NEXT CONSECUT1V51-Y NUMBERED FORM 43e1s.a7o 7_70JOM GUAOI.r osr <br />