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SPAT$OF CALIFORNIA ' <br /> ORIGINAL THE RESOURCES AGENCY Do not fill ill int <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER.WELL DPJLLERS REPORT No. 374019 <br /> A-tice of Intent Na— _ State Well Na - <br /> Local Permit No.or Dltte t r ' �7 t�5 "Q Other Welt N ' <br /> (1) OWNER: Name (12)(12) WELL LOG: Total depth ft Completed depth ft <br /> Address l ! 'ate from It to ft Formation(Describe by color,character,size or material) <br /> City C 0424 ZIP <br /> (2) LOCATION OF WELL(See instructions): S117 A <br /> County �' �C �t�S`' Owner's Well Number �a — ►� SA cA <br /> Well address if i e t from above - 7 ° <br /> Township Range - Sectiony $. <br /> 4 X — C-� <br /> Distance from cities roads,railroads,fences,eta L Z-�- — t1-6 ' 'El` to r t/t.L <br /> 'L — e YO C, A. / <br /> lyz — /%5 ,.0 <br /> /F.S �. F <br /> (3) TYPE OF WORK ^ t94, <br /> New Well 0:Deepening ❑ C1 9 <br /> Reconstruction ❑ � v <br /> Reconditioning ❑ Zd <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe — `�- <br /> destruction materials and pro- `` 'L- r. <br /> cedures in Item 12) ,` 1, <br /> (4) PROPOSED US ",..€/ — c/ <br /> Domestic <br /> Irrigation <br /> Industrial ❑ — <br /> Test Well ❑ <br /> Munici VV ❑ _ . <br /> O er "t _ <br /> WELL LOCATION SKETCH — <br /> (5) EQUIPMENT: ( GRAVIlk �CK: <br /> Rotary Reverse ❑ �\ Noo S 7 <br /> Cable ❑ Air ❑ is et of bora <br /> Other ❑ Bucke a 6 <br /> (7) CASING INSTALLED: (8)PER Q ATf ^ <br /> steel ❑ Piastic ret Ty of f onorsizeof <br /> From T 'Na.iGageor — <br /> & fk iA wall — <br /> v <br /> (9) WELL SEAL: — <br /> Wassurfaessaattarysealprovfded? Yes)s? No❑ Ifyef,todepthl�� ft <br /> Were strata sealed against pollution? Yes`W No 0 Interval—ft, — <br /> Method of sealing G Work started 19— Completed—l' <br /> om leted 1 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known °I-� ft This well was drilled undertnr fur udiction and this report fs true to the <br /> Standfaglevel after well completion R best of my knowled a and beltRee <br /> (11) WELL TESTS: Signed , <br /> az wen test made? Yes❑ No❑ IE yes by whom? /��4sr(Well Driller) <br /> ype of test Pomp❑ Bailer❑ Air lift ❑ NAME i--A C? <br /> h fo waterat start of test it At end of test ftyfPersoa, or corporation)(Typed or printed) <br /> Discharge gel/minafter hours .Water temperature Address—,�"a 4% <br /> Chemicalanalysismade? Yes No,$ Ifyes,bywhom? City_ Jda �' � ' r"�' ZIP <br /> g,�, ii•.S <br /> Was electric log made Yes❑ No IE attach copy to this report License No r Dote,df thi;report <br /> OVIR tee W".12-86) IFF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMOMED FORM t 06 96355 <br /> s <br /> SFC /7 03A169,E X3 <br />