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$TATE OR CALIFORNIA <br /> ORIGINAL THE RESOURCE5 AGENCY Do not fill in <br /> ' Fele With DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 319626 3 7 a <br /> notice of Intent No State Well No. <br /> Local Permit No or Date Other Well No <br /> (1) OWNER Name � (12) WELL LOG Tutal depth ft Completed depth ft <br /> ' Address 13 - <br /> From ft to €t Formation(Describe by color character size or material) <br /> City ZIP L:5: <br /> (2) LOCATION PF WELL (See instructions) <br /> ( onnty tt s '44�i� Owner s Well Number W' — T <br /> Well address if different from above 2 -s� <br /> Township Range rp Section - N �Lt 02S 67� 434-T) <br /> Distance from cities, roads, railroads,fences,etc h&LJO <br /> 1.t3 i <br /> ' (3) TYPE OF WORK <br /> New Wel! ❑ Deepening ❑ <br /> Reconstruction ❑ <br /> ' Reconditioning ❑ <br /> Horizontal Well ❑ �� <br /> �\ <br /> Destruction El (Describe <br /> destruction materials and ^f <br /> pro- <br /> 11 <br /> cedures in Item 12) - <br /> (4) PROPOSED USf <br /> Domestic ^ <br /> Irrigation _ <br /> Industrial <br /> Test Well \ <br /> 4luntctrl l <br /> i <br /> WEL.I_ L(}C MONJ SKE I(H r lt�tst[1be) <br /> 5) E.QUIPMPNT obi L RAVk' FkA-CK Rotary `j R.,wrrst { Yi ❑ Vo~,r—I �— <br /> Cable 1 J Air \1eter of bare <br /> Othrr i fiva key—y_. Packed from to ft- <br /> ' {-1 CASING lMS AALLLJ) t 1� t (8) PERp(5R``A``n0NS -- --- <br /> Steel ❑ Plastic ❑ octet Ty of�tto,htlon or sue of U <br /> From T l Gags orb,t - <br /> ' ft f t Wallv size -- --' <br /> 19) WELL SEAL <br /> Was surface s-amtary peat pmvtdr d? Y.� 1u J If Y" to depth Ft I — <br /> W�re sFrata sealed a(�atnst pollution' YaK ' Vu {ntrry it __ __ T ft �- ---_- — —�-f� --- <br /> ' fit thud of-Mling _ T _ : -----__ Work st.irted39- <br /> 00WATER LEWELL DRILLERS STX-ITFMF,\-1 <br /> Depth of first water if knowu <br /> 7 hn well ua, drilled i,nele r eny junedu Etrlri mill chis rt y+ c t", Io rh. <br /> 4tandmg level atter well cvmplrtiun =v — JJ _T— - is lX si i(m nnn lgtlgr nri 1iA,f <br /> f <br /> (11) WELL TESTS 5t>nrd 1 _ <br /> as well test made Yc_ 'I re , wo u3,i' _ __ <br /> iFtrst PUMti r iliEcr T 1sr'fi T <br /> ' MK;th to water at start of test it III en,i of trht — —_ jO (P forret or to tmnl(Typed nr pante t) <br /> Discharge gal/min 3ftec lw< 'Nit, iNm}xranir, Icldrets "7 <br /> Chemical analysis made Yea iL�" Vo I If rs b,wham? (71ty ZIP <br /> Was electric tog made yes L1 No [_1 If yes,attach copy to this report License No. Date of this report <br /> DN,R 188 cREV 12-136) IF: ADDITIONAL- SPACE IS NEEDED VSE NEXT CONSECVTIVELY NUMBERED FORM <br /> tib 44353 <br />