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t'-- <br /> �� o '� <br /> QUADRUPLA y TES <br /> STATE OFCALIFpRNI --'� <br /> Use;to corral 1 with ; 1�8� Do not I M <br /> local requirements THE RESOURCES AGENCY ' <br /> I! DEPARTMENT OF WATER RESOURC S ' <br /> _ , ���:k,P� No. x837$?.W.�^�.^ <br /> WATER WELL DRILLERS ' <br /> Notice of Intent No. - "r -_ <br /> u _ _ telt IPSe `ell No. <br /> Local Permit No. or Date <br /> — <br /> Well Well No. a , <br /> I bre l r`... , e <br /> I Herman Van R n � .. <br /> 11m "Sw <br /> 1 ` .9 6 ,?x o oa y (12) WELL LOG: Tot I depth wft. Depth of completed we[ "v,_ <br /> Address from ft. to ft. Formation {Describe by color, character, size or material) <br /> City <br /> II ! r <br /> I zip OpBO <br /> i (2) .;L0t00 &fU)WLL (See instructions): - TOtvn (' ay <br /> COtum� Owner's Well Number – grave <br /> { Well address if different from above <br /> t - <br /> -12 <br /> I Township Range Sectio <br /> Distance fmm cities, mads, railroads,fences,etc. <br /> ! _ ir- taxid <br /> wx <br /> 11±2 <br /> i , <br /> _ (3) TYPE OF WORK: _" <br /> New Well C�Deepening ❑ <br /> 'AY-with stzeake or- <br /> Reconstruction ❑ _ <br /> Reconditioning ❑ <br /> i I <br /> !: ? Horizontal Well ❑ _ <br /> Destruction ❑ {Descri e – <br /> destruction materials <br /> procedures in Item – <br /> (4) PROPOSED Tnsite!13 IS <br /> Domestic <br /> r <br /> • <br /> Irrigation the - <br /> 0 <br /> ' - Industrial ❑ <br /> _ T s Well ❑ _ <br /> Stoc <br /> ` - Municip. , <br /> i WELL LOCATION SKETCH[ Other ❑ _ <br /> (S) EOIlIPMENT: (6) GRAV ACK: <br /> I <br /> Rotary El Reverse ❑ . ❑ No Siz <br /> Cable `] Air ❑ r of bore <br /> Others ❑ Hucket ❑ mm tt _ <br /> (7) CASING INSTALLED: (8) PERFORA lbkk _ <br /> Steel ❑ Plastic ❑ Co • e Type of pe a or ze of scree – <br /> Fmii <br />