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QIIAGQUpLICATF. STATE OF CAYIFORNIA _ ((gy�pp DOOE fill inUse to comply with 'lI <br /> THE RESOURCES AGENCY 1JOO <br /> local requirements DEPARTMENT OF WATER RESOURCES No. 086662 <br /> Notice of Intent NR WATER WELL DRILLERS REPORT <br /> 3 - statf�'�ell No <br /> Loral Permit No. or Date ga4•74 - Other Well No. <br /> (1) OWNER: Name 04waald Ke" (12) WELL LOG: Total depth 34%. Depth of completed wen340 <br /> Address 9041 10. 1pise Road from ft. to k. Formation (Describe by color, character, size or material) it, <br /> City 6-toe M. a Rdip 0 - 8 o so <br /> (2) L(j W1%*jj'ELL (See instructions): $ - 3 -own C ay <br /> (:"only Ownei s Well Nmnber 3 - oeka, <br /> \\ell address if different form above 3 - room y <br /> 'r:ownshitrRange --Secyo - ravo ^1 <br /> Distance from cities, mads. railroads,fences,etc. AOR sl - <br /> �a averas Ro&40and 6.00E of 1 Ras - <br /> Road - <br /> (3) TYPE OF WORK: <br /> ' New Well Z Deepening ❑ <br /> brown sand- <br /> _ Reconstruction ❑ _ <br /> s ` ReconditioningBrown <br /> ❑ - <br /> .�"` Nonzontal Well ❑ - <br /> 6146r <br /> `r Destruction ❑ (Describe - <br /> y destruction materials pV brown Ciftv �.� <br /> t r i➢ prncedures In Item IlLia C\ <br /> (4) PROPOSED <br /> Domestic - - <br /> S2{ Irrigrdan O --E1r telQ .a <br /> � �`-- IndusMal ❑ <br /> Weuv ❑ <br /> St t <br /> a ""''V o`n t and I am not resp <br /> WELL LOCATION SKETCH Other ❑ for alItrina or removing nf rhoy <br /> t.5) EQUIPMENT: (8) GRA" <br /> AA PACK: a -Q Caning, n <br /> lictaq [IReverse ❑ ❑ N Si <br /> Cable Air ❑ er of bure - <br /> Other ❑ Bucket ❑ m - <br /> (7) CASING INSTALLED (S) PERF0It - <br /> Steel a Plastic ❑ C c Type of pe nor a of score - <br /> Fmnt TDia. r F To - <br /> ft. f in. Wall f , ft. s+ - <br /> (9) WELL SEAL: s - <br /> Was surface sanitary seal provided? Yes C] No lS If yes, to depth ft. <br /> Were strata sealed against pollution? Yes ❑ No [* Interval ft. - <br /> Method of seali e Work start 1 Complet 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know. ft. This well vas drilled under on, jurisdiction and this report is trite to the ben of my <br /> Standing level after well completion ft.. knowledge and belief. <br /> (11) WELL TESTS: SIGNED <br /> \Vas well test made? Yes ❑ No 1; If yes, by whom? (W Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME Panto 1/!11 �rillin,3, IaC� <br /> Depth to water at start of test k. At end of test-ft fim,++.� ��c��nrynra{1.nv) (Typed or printed) <br /> Dis.lu rge gal/min after hours Water temperature Address 314 ��L• LV4e +tee RoaA <br /> Chemical analysis made? LIYes ❑ No ❑ If yes, by whom? City Oakda33Tle Calif Zip 95361 <br /> Was electric log made? Yes ❑ No ❑ If yes, attach copy to this report License Nn, Date of this report 6/5/80 <br /> DWR 188 1REV.7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />