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i4UAi0RUPTI.:CAYL
<br />Use to comply with STATrt OF CALIFORNIA
<br />local regiArements THE RESOURCES AGENCY
<br />DEPARTMENT OF LWATER RESOURCES
<br />Notice of Intent No,�_ � WATER WELL, DRILLERS REPORT
<br />Local Permit No. or Date �- -' Z-4 �,{ r s�" I ,
<br />(1) OWNER: Mme < /�,Qv_ /� Et, C
<br />Address
<br />� ' city '�' %rfC/'.' 7 G''✓ti �� t,n r
<br />2 L 1G,�4TIOiOF WELD I�
<br />QJC/ � /-�l f1//1l (See instnietions);
<br />County Owner's Well Number
<br />Well address it different from above .I!
<br />/ /`
<br />Township !!�" Ranges Section
<br />Distance from cities, roads, railroads, fe
<br />f
<br />II
<br />(3) !'TYPE OF WORK:
<br />New l V ,11 6 Deepening ❑
<br />Reconstruction 0
<br />Recniiditinning ❑
<br />liorII
<br />ir to Well ❑
<br />I
<br />�.�
<br />Destruction
<br />n ❑ (Descri e'
<br />destriictinn materi
<br />A/) l procedures in Itemals
<br />.(4) "PROPOSED
<br />7 Domestic
<br />I)
<br />Irrigation
<br />�l
<br />Industria[
<br />T Welt ❑G
<br />Stoc
<br />Ivlunicip
<br />- `II
<br />Do not fill in
<br />No. 118357
<br />EhilelliE.
<br />nPv—
<br />(12)
<br />WELL LOP. Total depth ?r ft. Depth
<br />�/��(t•
<br />_V5 !''i Al D40-17-1
<br />(5) EQUIPMENT:
<br />Rotary ❑ -Reverse ❑
<br />I Cable Air ❑
<br />Other ❑ Bucket. ❑
<br />of completed well
<br />from ft.
<br />to k. Ton -nation ( Describe by color, character, size or material )
<br />✓ •- '
<br />(7) CASING INSTALLED:
<br />I Steel Plastic ❑ Co a
<br />Y �--
<br />O, - 741V [
<br />j
<br />N/?1, k Al �J c
<br />F
<br />ft.
<br />Tn
<br />ft. i
<br />3 - 1 t`'/� % �;4x1A)f1
<br />16'-'
<br />- L-7
<br />it :f../Nx s/ IL 7-
<br />'-Z
<br />(Welt Driller
<br />NAME �"-'��rYf �,��"C'�' �/?1 t•"'�'-''��� - '
<br />Depth to water at start.. of test
<br />ft. At end of test
<br />ft
<br />rt/
<br />f (9) WELL SEAL: ii
<br />Was surface sanitary seal provided? Yes es.•-_ No Q If yes, to depth ft.
<br />` ,I
<br />Were strata scaled ag st )ollutinn?Y ❑ Neap ft.
<br />Method of sea li
<br />_
<br />6,& V r" [-
<br />- -
<br />r, .
<br />No If yes, by whom?
<br />City -J'
<br />Vii{} tW O . 'fj/�A J / Al( V�
<br />Was electric loft made? Yes ❑
<br />No ( If yes, attach copy to this report
<br />License No. i� Date of this report
<br />�
<br />1
<br />7
<br />_ C.
<br />0, `iii
<br />A491,
<br />WELL LOCATION SKETCH
<br />Other'' ❑
<br />_V5 !''i Al D40-17-1
<br />(5) EQUIPMENT:
<br />Rotary ❑ -Reverse ❑
<br />I Cable Air ❑
<br />Other ❑ Bucket. ❑
<br />(6) GRAV ACIl:
<br />❑ No
<br />r of bore -�
<br />1 rum �I h
<br />/
<br />I�
<br />r: '�. ; 7 :'-•
<br />✓ •- '
<br />(7) CASING INSTALLED:
<br />I Steel Plastic ❑ Co a
<br />(8) PERFORA I
<br />Type of per a or ze -of scree
<br />O, - 741V [
<br />p - ,/ a.3 rW n 54.,,,, €� T
<br />I From To Dia. Ga r
<br />ft. ft i Wall
<br />F
<br />ft.
<br />Tn
<br />ft. i
<br />3 - 1 t`'/� % �;4x1A)f1
<br />SIGN,—
<br />made? - ❑
<br />Type of test Pump ❑
<br />No [ If yes, by whom?
<br />Bailer ❑ I� Air lift ❑
<br />(Welt Driller
<br />NAME �"-'��rYf �,��"C'�' �/?1 t•"'�'-''��� - '
<br />Depth to water at start.. of test
<br />ft. At end of test
<br />ft
<br />( erson, firm, or -corporation) (Typed or printed)
<br />f (9) WELL SEAL: ii
<br />Was surface sanitary seal provided? Yes es.•-_ No Q If yes, to depth ft.
<br />` ,I
<br />Were strata scaled ag st )ollutinn?Y ❑ Neap ft.
<br />Method of sea li
<br />_
<br />-
<br />- -
<br />lwL
<br />n
<br />Work -start T - 19 Completed
<br />(10) WATER LEVELS:
<br />/
<br />I�
<br />WELL DRILLER'S:.STATEMENT:
<br />Depth of first water, if known
<br />Standing level after well comp3etina__
<br />✓
<br />ft.
<br />tt,
<br />This well was drifted ander mfr jurisdiction nnrl this report is true to the Beat of rnU
<br />knowledge
<br />_
<br />_ �I r
<br />(11) WELL TESTS:
<br />Was well test Yes
<br />SIGN,—
<br />made? - ❑
<br />Type of test Pump ❑
<br />No [ If yes, by whom?
<br />Bailer ❑ I� Air lift ❑
<br />(Welt Driller
<br />NAME �"-'��rYf �,��"C'�' �/?1 t•"'�'-''��� - '
<br />Depth to water at start.. of test
<br />ft. At end of test
<br />ft
<br />( erson, firm, or -corporation) (Typed or printed)
<br />Discharge gal/min after
<br />11
<br />hours - Water temperature
<br />I C7 c.•
<br />Address
<br />/1 ✓/�/��S
<br />'r
<br />Chemical analysis made? Yes ❑
<br />No If yes, by whom?
<br />City -J'
<br />Was electric loft made? Yes ❑
<br />No ( If yes, attach copy to this report
<br />License No. i� Date of this report
<br />DWR 188 (REV. 7.715) IF ADDITIONAL SPACE -1S;NEEDED. USE -NEXT CONSECUTIVELY NUMBERED FORM.
<br />li
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