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�— rST®�ADo not Il I' <br /> QUADRUPLICATE v LI N 251979 <br /> a ill <br /> locl r Comply with STATE OF CATHE RESOURCES AGEN fill <br /> focal requirements <br /> 152168 DEPARTMENT OF WATER RE S LOCAL No. 05161 <br /> Notice of Intent Nn. WATER WELL DMLLL�j � TRICT State Well No._ <br /> Local Permit No. or Dat 70—jOther Well No. Zf Ar#�9 <br /> (1) OWNER: Name John Van de Pol (12) WELL LOG: 160 160 <br /> Total depeh ft. Depth of completed well h. <br /> Address 16996 s7lon Road I. ft. to h. Form i n (Deceribe by color, chnmuter, size c mn[ertaq <br /> city eoa on, _ <br /> �iP <br /> 4- 24 Clay <br /> (2) LO&A1T _QE_ff LL (See inswctiona): _ 35 <br /> County ��u+j+ Owner's Well Number <br /> Well address ifati9er formals. 00 <br /> — <br /> Township Z s7 Ron <br /> ge--�---�¢��v�t� — <br /> D't fm tbes ds milmads,I. res.atc. A'�JU(o w — <br /> Y�� sok�oh126 - and 01" 3*702w— <br /> (' (3) TYPEOFWORK: <br /> .1 New Well a' Deepening ❑ <br /> �.1 Reconstruction ❑ — <br /> Reconditioning ❑ — <br /> Hoo.naal Well ❑ — <br /> (+ — <br /> '' Deatmctivn ❑ (Descri e <br /> i.L deatmctinn materiab <br /> Procedures iv Item - <br /> ------ (4) PROPOSED8 Insr.9110a <br /> )` Domestic <br /> Irrigation ❑ SkIT'S or rejuavIng al DIM <br /> �I' ]ndnatrtal\ ❑ or <br /> '...;..___.._ _..._, _' .._... _._. ._. Well J ❑ <br /> 5Rw — <br /> Mumr'i <br /> WELL LOCATION <br /> SKETCH Other ❑ — <br /> (5) EQUIPMENT: (B) GGzRIA ACK: — <br /> Rotary (7 Reverse <br /> El No S' <br /> Cable ❑ Air ❑ r of bore — <br /> Other ❑ Bucket EIrom <br /> (7) CASING INSTALLED: (8) PERF <br /> Steel ❑ Plastic lT Co a Type of pe a or a of scree — <br /> Front To Dia. Ga r F To — <br /> ft. ft i Wall ft. ft. S' - <br /> MY M _ <br /> (9) WELL SEAL: _ 50 <br /> Was surface sanitary seal provided? Yes ❑ No ❑ If yea, to depth h. <br /> Were strata sealed agaimt pgll�stione?nyes ❑ No F Interval ft. — <br /> Method of welin UU OOHS LL Work started 19_ Complet 19_ <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known 6e (q This welt was drilled under.my jurisdictioµ n+ report is tom to the ben of my <br /> Standing level after well completion Ib knowledge andlbeliff._ <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes E] No� If yes, by whom? 1 r <br /> Type of teat Pump ❑ Bailer ❑ Air lift ❑ NAME Panero wellW lbkffiing: Inc. <br /> Depth to water at start of test h. At end of test a ,(Prgp t��rs_,, ati ed) <br /> Discharge oaI/min alter boon; Water temperatureAddress 31st'JV n-- , qs rsp@ty yA,1_(Typ¢d, 60 <br /> Chemical analysis made? Yea ❑ No ❑ If yes, by whom?_ City Oakdale, <br /> Call •/2'CC iff7�7 <br /> 11 Y3361 <br /> Was electric Ing made? Yes ❑ No ❑ If yes, attach copy to this report License No. Date of this repos <br /> own 188 1"s V.7"761 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />