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ORIGINAL THE RW;OURCEAGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES DD not rill in <br /> WATER WELL DRILLERS REPORT N0. 313821 <br /> Notice of Intent Na Slate Well No. <br /> Local Permit No.or Date g� ` ��� 9/ Other Well Na <br /> (1) OWNER: Name (12) WELL LOG: Total depth—t?--ft Crsmpleted depth ft <br /> Address from ft, to ft. Formation(Describe by color,character,size or material) <br /> City yip <br /> ' (2) LOCATION OF YELL(See instructions): }Sr�� <br /> ( nmty Owner's Well Numher — e>r2!20-f 0266W <br /> Well address if different froq9 _ <br /> 1 Al - <br /> Township Range � _Seclinn <br /> Distance fmM cities,nuds railroads,fences.etc. <br /> GA TYPE OF WORK: - <br /> - <br /> New Well ❑ Deepening ❑ <br /> 1nTf�feJ 5 f' Reconstruction ❑ — <br /> Recanditfoning. ❑ <br /> Horizontal Well ❑ — <br /> f}p0 �/ Destruction ❑ (Describe <br /> f� y x�ACT1oA) desltuction materials and pro- <br /> QrlR y Well ceduresinItem 12) 22 <br /> ® (4) PROPOSED US _ <br /> Domes)ic oolr^ — <br /> . Irrigation <br /> �] industrial ❑ _ <br /> L�. Test Well O ❑ - <br /> V Munici� © _ 0 <br /> W er bc) V <br /> ELL LOCATION SKETCH <br /> 45)EQUIPMENT, CRAYCK: — - <br /> Rotary❑ - R<veele ❑ Na l <br /> Cable ❑ Air 11et oI bare <br /> Other ❑ Ruck 'ed rom <br /> (7)CAS[ N A (a)PEATl _ <br /> Sled ❑ Plartfc TYPR urs r <br /> From Gageor t - <br /> ft. I Wail t. size - <br /> d - <br /> (9) WELL SEAL: - <br /> Wumrfiwasanitary*.dpnwiled? Yea$ No Cl Ifyet,lodepth Z!t fc — <br /> Were stntateaWagainst pollution? Ya❑ No$ Into esft. — <br /> htelhoddaalln= Work started l9 Completed l9 <br /> (10) WATER LEVELS: WELL DRILLERS STATEMENT: <br /> Depth d Fina-- vales,if known —+ -- Ec-- ------- -- -- - - - --- -- - This melf was drilled under m yurisdict'on a d this repos is true to the— -- -- - -- <br /> StandinRkrtlaft—liompktion It- best of myknowl Bean betel - - -- <br /> '11) WELL TESTS: Signed <br /> _ Val A lett made? Yes❑ No❑ if ym by wham? i W rl <br /> Typeoftro Pump❑ Ruler❑ Airlift ❑ NANtE <br /> Depth to waletal Mart of telt ft At end of tell ft f e 'mc or corponitionWry <br /> Dirchailte pi/min after hours Waterternperatrert Add, ZL <br /> e - <br /> ChemicalanalyusMade? YM❑ No❑ If yn,by whmm? - City ZIP <br /> - Wa■eleetrlckmgmade Yes❑ No❑ Ifymatlacheapytethisreport - LicemeNo, Date of this re rt <br /> owR IGO IREV. I2-nat 19 ADDITIONAL SPACE IS NEEDED, USE NEKT CONS GUTIVELY NVMBERED FORM - N 94335 <br />