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ORIGINAL STATE OF CALIFORNIA Do not fait in <br /> File with DWR THE RESOURCES AGENCY '�0.2 9 3 4 9 <br /> DEPARTMENT OF WATER RESOURCES <br /> 1 Notice of Intent Na WATER <br /> WELL <br /> 1L DRIiL7LRs RF p®RT 1,0 <br /> tsyefINo._3N G--a,.t t`, <br /> ical Permit No.or Datt+ Other 1Ye11 No, Yi ) <br /> OWNER: a>n (12) WELL LOG: <br /> Total deptl:;��1t Depth of completed Ave <br /> Addmss from it to it. Formation (Describe by color, chanter. size or material) <br /> City —_ �— . P _ 0-- <br /> (2) <br /> ' <br /> (2) LOCA N F L r (See instructions): <br /> County Owner's Well Number <br /> Welt address if different ora a`v (o <br /> Toivnship--.& ----Range sectio <br /> Distance from cities,roads,milmads,fences,etc - <br /> C1 <br /> (3) TYPE OF WORK: <br /> s <br /> Now Well A Deepening Q <br /> _+ Reconstruction [� Z <br /> Recnnditioalag ❑ <br /> Horizontal Well Q _ <br /> Destruction 0 (Describe <br /> destruction materials d <br /> � r Procedures in Item _ <br /> (4) PROPOSED <br /> Domestic <br /> Irrigation\ _ <br /> f'h;_b i`"v industrial [j12 <br /> t Well`\` E3, <br /> Muafei <br /> WELL LOCATION SKETCH Other p <br /> (s) UIPMEN-T: (B) GAA PACK: <br /> Rotary.-A- Reverse Q NoNO Size <br /> Cable D Air ❑� tar of 6om \ <br /> Other 0 Bucket 0Is o _ <br /> (7) CASING INSTALLF.D (8 P.RF Ss <br /> Steel 0 Plash t Type of p n o •e of some _ <br /> From TDia. r F To <br /> ft. #. in. W ll <br /> (S) WELL SEAL: c')` <br /> Was surface sonitary seal provided? Year No 0 If yes,to depth n-- ft, _ <br /> Were strata sealed against pollution? Yes No Q Interval _ft - <br /> Method of sealfn- Work started 19 Complete g <br /> (10) WATER LEVELS: a� <br /> WELL DRII,LER'S. STATEMENT: <br /> Depth of first water, if kaewr+ ft' This mall ttw drilled under mu Jurisdiction and this report is trite to the best of mu <br /> Standing level after well Mate tion- ft knowledge ang belief._ <br /> SIGNm�,�t_ !�2A d 44� <br /> Was well test i.Zae?- yes 0 Y Y£ es, by whom? (Well Driller) <br /> Type of test ':9* [] Butter❑ lift D NAM <br /> E too"111 <br /> Depth to water el,at start of test n ,r' At end of test f+ (person,fin <br /> or corporation) (T)Ipedox)prin ) <br /> Discharge -rAddressd �. t t-c? , <br /> —_-, y^'gl/mrhi:atftec hears Water temparahcro Q <br /> Chemical analysis made? YtS Q '.No If yes,by whom? ptY pay rF _ <br /> ectric log made? Ye$ O if Yes,attach copy to this report License No ate of t�b4,pot 1p-W) TREY,7.75) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY(NUMBERED FgRM I 43et9-0a07_793oat aurn(Drosp <br /> 6)3/V 0$E <br /> S°'�C 9 <br />