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ORIGINAL STATE OF CALIFORNIA Y Do not fill in <br /> THE RESOURCES AGENCY NO. 191523 <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> Local Permit No, or Date Other well No<) <br /> (1) OWNER: Na e / (12) WELL LOG: Total depth�--_-)ft. Depth of completed well 7(/ ft. <br /> Address ' ? da2d from ft. to ft. Formation (Describe by color, character, size or material) <br /> City Zip <br /> (2) LOCATION OF WEA L (See instructions): <br /> %3/4,Ur � _ <br /> County h4JL JC'� CA 1 W Owner's Well Number <br /> Well address if different from above <br /> Township L/%1 1�1 )L rl Range Sectio <br /> Distance from cities,roads, railroads,fences,etc <br /> ` (3) TYPE OF WORK:: <br /> New Well k Deepening ❑ OF <br /> G Reconstruction ❑ - <br /> - <br /> �'� � Reconditioning ❑ - <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe - / <br /> destruction materials 1 n <br /> procedures in <br /> It <br /> - ✓/ <br /> (4) PROPOSED +- j <br /> Domestic <br /> cIrrigation ❑ <br /> `r _ <br /> v � Industrial � ❑ <br /> '» T Well ❑ - <br /> Stoc - <br /> Municipa - tp\ <br /> WELL LOCATION SKETCH >Other ❑ <br /> (5) EQUIPMENT: (6) GRAVINACK: <br /> Rotary Reverse ❑ Xes (I7 No Size <br /> Cable ❑ Air ❑ <br /> h titer of bore o - <br /> Q <br /> Other ❑ Bucket ❑ ro —t - <br /> (7) CASING INSTALLED:j (8)�'ERFORA' <br /> Steel Plastic ❑ Cottfr a Type of perftx by or <br /> Plastic of screen <br /> From To Dia. Gag dr Fr b J To <br /> ft ft. in. Wall ft. \ ft. 4w - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes No ❑ If yes, to depth_�=5a_ft. - <br /> Were strata sealedagainst utfo ? es o ] Interval ft. <br /> Method of sea' Work start 19 ComPlet 19 <br /> (10) WATER LEVELS: va + %�\ 1 WELL DRI'LLER'S STATEMENT: <br /> Depth of first water, if known -I 440This well �tlte�u <br /> rnder my jurisdiction an this report is true to best o/ m1 <br /> Standing level after well completion t Y1-� ft, knowledge n��d elief. <br /> (11) WELL TESTS: SICNsn <br /> Was well test made? Yes ❑ No If yes, by whom? (Well Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME y <br /> Depth to water at start of test ft. At end of test ft (Pe`on, fi or crati ) (Typed or printed) <br /> AAA— <br /> Discharge-_--gal/min <br /> ddressDischarge gal/min after r:houWater temperature <br /> City Z+p <br /> Chemical analysis made? Yes ❑ No If yes, by whom? / <br /> Was electric log made? Yes ❑ No If yes, attach copy to this report License No. ate of this repo <br /> DWR 188 (REV.7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />