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QUADRUPLICATE STATE OF CALIFORNIA Do lot <br /> Use to comply with fill iN <br /> local requirements THE RESOURCES AGENCY <br /> _ DEPARTMENT OF WATER RESOURCES No. 075514 <br /> ' �� WATER WELL DRILLERS REPORT <br /> Notice of Intent No.' - State Well No. <br /> Local Permit No.or Date _ T <br /> Other Well No. <br /> (1) OWNER: Nam Ivr f� h/ 7` v, (12) WELL LOG: Total dept�J fL Depth of completed wet -fo ft. <br /> Addres `� G:�7-1 l c Li -t r 1L F7 7/C! from ft. to It. Formation (Describe by color, character, size or material) <br /> city l,l e t'l r /C L /T _ <br /> Com L ATIOAL OF WELD,,, (See instructions): - y/rJ C/iy ` <br /> County "�A''� ✓Ga C n Owners Well Number - / .1 O,L, r"- L f r fel t ..y � • <br /> Well address if different from above .�.'C JrU fU. S.',Nr T a : iN;, 'tj! - Ern aLr�✓ / M <br /> Township iy�-fir i' O Rgng._S - <br /> h Y road, railroads,houses,ec sDistance from cities, <br /> I/, C 3rVioi. LsYNl/I✓'✓ {L,.. <br /> /J <br /> J - 10 <br /> Jiq 14 /� Rd (3) TYPE OF WORK: <br /> J <br /> New WeB)( Deepening ❑ J <br /> Reconstruction ❑ r14-� <br /> 4�. Recond;tiouing ❑ <br /> \ Horizontal Well ❑ <br /> y Destruction ✓tl S f<":J , <br /> destruction m❑ (Describe <br /> 14 Pmcedura iv Item - - <br /> �( K %si <br /> .(F1c.. (4) PROPOSED - , �; f I <br /> 3 Domestic <br /> ati, Do - f r•v C' ,I <br /> Irrigation <br /> Industrial ❑ <br /> %Wull 13, <br /> L.et� �: R <br /> T _ /- ✓ f <br /> Mumeip <br /> Cg <br /> WELL LOCATION sXETCH ether ' :J <br /> (5) EQUIPMENT: (6) CRA PACK: <br /> J� <br /> Rota <br /> ry ❑ Reverse ❑ ❑ No S' _ <br /> Cable � Air ❑ r of bore <br /> Other ❑ - Bucket ❑ ro <br /> CJ:G O I r Vr <br /> (T) CASING INSTALLED (8) PERFORA <br /> f <br /> Steel Plastic ❑ C Type of pe v or• e ofscree - 173 _r t• N C1 X t <br /> From T Dia. r Ff&V To - '- �' r -% < 0 r ✓ C /i.+ <br /> ft. f in. Wall ` `" - Y ,r V 1✓/J L A <br /> 5�2 - "DS 6recd A/ <br /> (9) WELL SEAL: 2!.>1 - O .... <br /> Was surface sanitary seal provided? Yes No ❑ If yes, to depth J n st _ 1 f f. / <br /> Were strata sealed agginst pollution? Yes(V No ❑ interval st _ ���� p.1r.^/.1.�%✓ N <br /> Method of sea r l' l r D� 1` Work ant19 Completed - 19 <br /> (10) WATER LEVELS: t7 WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know This sue/l sone drilled under y turhdiettoIt and this report is true to the bee of my <br /> Standing level after well completio l op knowledXe_and belie fj rr <br /> (11) WELL TESTS: SIGNED/�e.:r"'•- ;z,-C.-�- <br /> Was well test made? Yes ❑ No,' If yes, by wham? -J (Well Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ - <br /> NAM ,F. -� /�>> r e, :� ✓ C f f•�� "'.t 4 )!i: 7 L(-. 1 :t/ ('.- <br /> Depth to water at start of test n. At end of test w (Person, firm, or corporation) (Typed or printed) <br /> Discharge oat/min after houzs Water temperatureAddress !) r""7 <br /> G Chemical -- <br /> analysis made? Yes ❑ No� If yes, by whom? City�^- �- <br /> Was electric log made? Yes ❑ No JK If yes, attach copy to this report Liceme No. nate of this report <br /> OWR HIS (REV.7-76t IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />