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ORIGINAL STATE OF CALIFORNIA _slyi I <br /> THE RESOURCES AGENCY Gi( 1 no not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 061372 <br /> Notice of Intent No. WATER WELL DRILLERS REPORT <br /> Local Permit No. or Date n 7 -] State Well No. __ <br /> Other Well No.. <br /> (1) OWNER: Name —CL� ' (12) WELL LOG: y <br /> I��, �� �n Total depth ��(t. Depth of completed well �/ <br /> Address ^^ ,V I,/ I from ft. to ft. Formation (Describe by color, character, size or material) <br /> City_ Zip �� C Q A .SQiVtf'x r , <br /> (2) LO ATIQN OF WELL (See instructions): 9 L �fz C <br /> County I-V Owner's Well Nwnber ZZ -3S <br /> %Veil address if different from above <br /> Township,7 e:a M l+.V Range Sectio - L• <br /> Distance from cities, roads, railroads, fences, etc. C - <br /> N� (3) TYPE OF WORK: <br /> New Well , Deepening ❑ <br /> n Reconstruction ❑ _ <br /> Reconditioning ❑ _ <br /> Horizontal Well ❑ _ <br /> Destruction ❑ (Describe - <br /> destruction materials <br /> procedures in Item - <br /> (4) PROPOSED <br /> .3 Domestic _ <br /> I rrigation�\ _ (^�~ <br /> 'A Industrial ❑ \'- <br /> t Well <br /> St - <br /> Municip - <br /> WELL LOCATION SKETCH Other - ❑ - <br />(5) EQUIPMENT: (6) GRA PACK: - <br /> Rotary ISd Reverse ❑ N'o Size - �J <br /> Cable j❑' Air ❑ iter of bore - ' <br /> Other ❑ Bucket ❑ 1 om -jt� - <br />(7) CASING INSTALLED: (8) ERFORA S. - <br /> Steel ❑ Plastic,K Ce c t Type of pe n or ze of scree <br /> From To Dia. G: r F To - J) <br /> ft. f >in. Wall ' f . ft. si - <br /> 0 3 - <br /> 1 <br />(9) WELL SEAL: - <br /> Was surface sanitary seal provided? Yes No ❑ If yes, to depth i�Q ft. - <br /> Were strata sealed against pollution? Yes ❑ No C] Interval ft. - <br /> Method of seal-Ln r Work started I 19 Complet 19 _ <br />(10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known R. This well was drilled under my ry.uadictian nn I rhi.e ¢Hort is true to the best of my <br /> Standing level whet weB completion <br /> k knowledge an bell <br />(11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No E] If ,yes, by .whom? NVell Driller) <br /> e <br /> Typof test Pump ❑ Bailer C] Air lift ❑ NAME_el���/1 dA ILLo�eeC <br /> Depth to water at star�Yes <br /> .t end of test ft �y r Per<nr1n, firm, or corp`nntinn Typed or printed) <br /> Discharge gal/ r �If <br /> Water temperatureAddress_;/.]'S ] /7 yf%rJ 4� <br /> Chemical analvs a eNo s, by whom? City— Zip �— <br /> Was electric log made? Yes ❑ No ❑ If yes, attach copy to this report License No. Date of this report <br /> DWR 188 (REV. 7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />