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s <br />QUADRUPLICATE <br />Use to comply with <br />local requirements <br />Notice of Intent No. <br />Local Permit No. or Date — <br />• • <br />STATE OF CALIFORNIA <br />THE RESOURCES AGENCY <br />DEPARTMENT OF WATER RESOURCES <br />WATER WELL DRILLERS REPORT <br />Do not fill in <br />No. 375403 <br />State Well No. <br />Other Well No. %✓Y14�'�$ts) <br />(1) OWNER: Name C--,)ICI£,b <br /> <br /> <br /> <br /> , <br />(2) LOCATION �-O-F--WELL See instructions): <br />County' : % V —j -"-Z J r Al Owner's Well Number , `t <br />Well address if different from above 1~ <br />Township 1 Range Section <br />Distance from cities, roads, railroads, fences, etc. <br />- <br />— <br />"'T-):!1-4, tALh r) i ie <br />— n <br />(3) TYPE OF WORK: <br />New Well ❑ Deepening <br />Reconstruction <br />Reconditioning <br />Horizontal Well <br />DestructionX (Describe <br />destruction-matbrials and pro- <br />cedures in Item 12) <br />(4) PROPOSED US<� <br />Domestic <br />Irrigation <br />Industrial <br />Test Well O <br />Munici <br />er <br />tbe) <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />— <br />— <br />Ile <br />` a <br />01\ V,_ <br />_ <br />0 <br />WELL LOCATION SKETCH < <br />— <br />(5) EQUIPMENT: <br />Rotary ❑ Reverse El <br />Cable ❑ Air ❑ <br />Other ❑ Bucke <br />GRAV CK: <br />No Siz <br />et of bore <br />ed rom <br />(7) CASING INSTALLED: <br />Steel ❑ Plastic ❑ <br />(8) PER TI <br />Ty of o 'on or size of <br />_ <br />From T i . Gage or <br />ft. f i Wall <br />t <br />t. size <br />— ' ° `' 2 10 <br />— i ; <br />(9) WELL SEAL: <br />Was surface sanitary seal provided? Yes ❑ <br />Were strata sealed against pollution? Yes ❑ <br />Method of sealing <br />No ❑ If yes, to depth <br />No ❑ Interval <br />ft. <br />ft. <br />- <br />— <br />Work started 19— Completed 19— <br />(10) WATER LEVELS: <br />Depth of first water, if known <br />Standing level after well completion <br />ft. <br />ft. <br />WELL DRILLER'S STATEMENT: <br />This well was drilled under m urisdiction and this report is true to the <br />}Jest of m no ledge and belief <br />Signed <br />g r (Well Driller) <br />NAME <br />(11) WELL TESTS: <br />Elne <br />Was well test made? Yes ❑ No If yes, by whom? <br />Type of test Pump ❑ Bailer ❑ Air lift ❑ <br />Depth to water at start of test ft. At end of test <br />Discharge gal/min after hours Water temperature <br />Chemical analysis made? Y -X01 No ❑ If yes, by whom <br />Was electric log made Yes El No If yes, attach copy to this report <br />fterso <br />firm or r tion) (T _ printed) <br />Address 14 <br />Cit 4 j ZIP 42192 <br />License N Date of this repo <br />DWR 188 (REV. 12-88) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />