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V � V <br /> QUADRUPLICATE STATE OF CALIFORNIA Do not fill in <br /> Use to comply with THE RESOURCES AGENCY /Jy p <br /> local requirements `79 DEPARTMENT OF WATER' RESOURCES 2 1978 . 061308 <br /> Notice of Intent No. WATER WELL DRILLERS rim0AW,Ul State Well No. <br /> Lucul Permit No,or Date HEALTI�!- N (.( a)We I No. <br /> �l <br /> (1) OWNER: Nome e G OAl // /t9 t J pp (( (12) WELL LOG: Total deptl�_n. Depth of completed well--- ft. <br /> Address " Q Ql L. .S/� �/J from R. to f. Formation (Descrihe by color, chamete, size or material) <br /> cityC a— 4 i ;p — Td J'O r <br /> (2) LQCATIO*OF WELL (See instructions): — �r <br /> County "r^+1/ ✓Oa/}y,/N > Ow y)p(e�,Nombe / /pr .� .i✓r <br /> Well addres i( Her t from shove 3Z0 7`r /'Ox/ G:r"r 195— —�p'�J 501.4 �� <br /> TowmhiP O���J N Range Sectio <br /> Distance from cities, roads, railroads,fences,etc. — 4 <br /> /Z- 'v . <br /> is? i6> <br /> (3) TYPE OF WORK: ff,3 �/ or s !A101 <br /> New Well 16 Deepening ❑ <br /> RCCOMtruction ❑ CA? — /,Zg <br /> Reconditioning ❑ ). <br /> Horizontal Well ❑ — <br /> Destruction ❑ (Describe <br /> `* destooctinn materials <br /> procedures In Item — <br /> J (4) PROPOSED - <br /> X Domestic <br /> aw <br /> Irrigation O — <br /> Industrial ❑ <br /> %Mu.i <br /> ❑ - <br /> - <br /> r uir r <br /> WELL LOCATION SKETCH Other ❑ — <br /> (S) EQUIPMENT: (6) CRA PACK: <br /> RMa6 BE,, ❑ No SIz — <br /> Cahle ❑ Air ❑ er of bore ra — <br /> Od rr ❑ Rocket ❑ mm J �/ — <br /> (7) CASING INSTALLED (S) ERFORA S: — <br /> Steel ❑ Plastid C s t Type of pe n or ze of.sc — <br /> Froin Trr, Dia. G r F TO - <br /> ft. f in. Wall ft. s' - <br /> O5el 140 16 o <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes76 No ❑ If yes, to depth—ft. <br /> Were strata sealed against milution? Yes ❑ No InterveL it. — _ <br /> Method of sealin Work startHI Complel 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of fin] water, If know t This lzdg rttu drill u m ion � laae A, ben o <br /> Standing level after well compkknown <br /> ft This well f my <br /> (11) WELL TESTS: SIGNM <br /> Was well lest made? Yes ❑ No ❑ H yeses 4y whom?— /{r/ (Well D+/'IIn �/j <br /> Type of test Pump ❑ Bailer Air lift ❑ A• / • G/`O,fs' (A�e-L/L/ /yJrl/[L <br /> NAME <br /> Depth to water at start of tear ft. At end of tut H (P firm,n4 corporation) ( Printed) v <br /> Discharge sal/miv Rfter hours Water temperatu2 Address "�/'O L//V-44 <br /> Chemical analysis made? Yes ❑ No ❑ If yea, by whom? City' �'L Q f <br /> Was electric Mg made? Yes ❑ No ❑ IF yes, attach copy to this report License No. O '7Q Date of this repo a" <br /> DWR 188 (REV.7.761 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />