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QUADRUPLICATE STATE OF CALIFORNIA Do not fill=n� <br /> Use to comply with THE RESOURCES AGENCY <br /> local requirements / DEPARTMENT OF WATERRESOURCES No. 075562 <br /> Notice of Intent No. C' �l _ WATER WELL DRILLERS REPORT State Well Ne._ <br /> Local Pemut No. or Date �/.���s ��O��t//h((er Well No. _ <br /> (1) OWNER: Name /!% (12) WELL LOG: Total dap 115-ft. Depth of ernnpleted well L& ft. <br /> Addres from ft/.. to ft Formation (Describe by coin, character,rter, size or material) <br /> City zip 7zsl�5 <br /> (2) LWAT30N QF WELL JSye instructions): <br /> County_f/' +% -" ' /•:r!/✓ Owner's Well Number <br /> Well address if different from above <br /> Township Rona, Seetin <br /> Mange from from utie, roads,railroads,feoccs etc. <br /> ' r r - <br /> (3) TYPE OF WORK: ) <br /> New Well/ Deepening ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ - f✓ N <br /> Horizontal Well ❑ - ( <br /> l S Destruction ❑ (Describe <br /> destruction materials aW / <br /> J pna"'dures in Item <br /> (4) PROPOSED <br /> Domestic <br /> O <br /> I 1 1 <br /> - <br /> 't � Industrial ❑ - <br /> 777 �. We ❑ <br /> Sto <br /> Municip I - <br /> WELL L ATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRA PACK: - <br /> Rotary ❑ Reverse ❑ ❑ No Siz - 1 <br /> Cable )K, Air ❑ r of bore - <br /> Other ❑ Rucket ❑ ro - <br /> (i) CASING INSTALLED (S) PERFORA S: - <br /> Steel Plastic ❑ C Type of Pe"n or a of scree - <br /> From 'I' Dia. r F To - - <br /> ft. in. Wall ft. s' - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? YesNo ❑ If yes, to depPo..:1 61 ft = - <br /> Were strata sealed against polution? Yes No ❑ Interval <j R. _ <br /> Method of sealin / Work started / 19= Completed 19 <br /> (10) WATER LEVELS: / WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known This u:ell rocs drilled under all, jurtsdiOwn and chis report is true to the best o/ my <br /> Standing level after weR comp]etin 3 '� k kno:nledg"d belief. f <br /> (11) WELL TESTS: SICNeD �--r <br /> f <br /> Was well test made? Yes ❑ No rL1t��'�(�f yes, by whom? (Well D Ilr ) / <br /> Type of test Pump ❑ . v nailer ❑ Air lift ❑ NAM I ,'y^(,/, t/ �r'- ���// i /: /i ✓� <br /> Depth to water at start of teat ft. At and of test ft (Persia, firm, or eorponrt-o) i Tylied .n punted) <br /> Discharge vol/min afterours Water temperature Address -" <br /> Chemical analysis model Yes ❑ No If yes, by whom? Crty� _. - z p- <br /> i <br /> Was electric Ing made? Yes ❑ No If yes, attach copy to this report License No. s <br /> Date of this repo / <br /> DWR 188 (REV.796) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I � <br />