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STATE OF CALIFORNIA T <br /> ORIGINAL THE RESOURCES AGENCY DO not fill in <br /> File With DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. <br /> N_7itice of Intent No. State Well No. <br /> Local Permit No. or Date Other Well No. Osd� o1M <br /> (1) OWNER: Name (12) WELL LOG: Total depth 42;" ft. Completed depth—5-3-7rft. <br /> Address L from ft. to ft. Formation(Describe by color,character,size or material) <br /> City— e G'J�': C�" ZIP d _ Z e <br /> (2) LOCATION OF WELL (See instructions): Z — <br /> County S4" Jpa- um Owner's Well Number o- <br /> Well address if differentom above - <br /> Township ��Range G F Section 517 <br /> Distance from cities, roads,railroads, fences,etc. <br /> , _ - <br /> 111'1w'� (3) TYPE OF WORK: <br /> New Well � Deepening ❑ \ <br /> Reconstruction ❑ - ��� ` ` <br /> Reconditioning ElFl&cA- Rd - <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe - <br /> CSC�I destruction materials and pro- . <br /> cedures in Item 12) ~ <br /> 3 - <br /> .r <br /> (4) PROPOSED USE:;-,. <br /> Domestic ❑ ,- . _ <br /> * Irrigation <br /> w Industrial \� ❑ / <br /> Test Well ❑ v <br /> /tber <br /> WELL LOCATION SKETCH �'�e�ertbe)1M1QzYf�+pf7• W _ '.` <br /> (5) EQUIPMENT: GRAVELPACK: <br /> Rotary El Reverse \ <br /> ❑ Yee No � Size <br /> v Cable <br /> ElAir 11 bore ~ <br /> Other f" Buckey_.Q C> from 20 Yo — <br /> (7) CASING INSTALLED: ` (8) PERPOR.ATIO tlS: <br /> OSteel ❑ Plash=� � Typ"E foration or size of <br /> From T Dia. Gage or \ TC(! <br /> ft, f in. Wail eft: \`. size _ <br /> (9) WELL SEAL: — <br /> i.r Was surface sanitary seal provided? Yes ys No ❑ If yes.to depth ft. <br /> Were strata sealed against pollution? Yes No ❑ Interval ft. — <br /> Method ofsealing '1;WELL <br /> Work started 19 Completed 19 <br /> (10) WATER LEVELS: (j DRILLE 'S STATEMENT: <br /> Depth of first water,if known J ft. <br /> This well was drilled under my jurisdiction and this report is true In the <br /> Standing level after well completion •Z� ftlust of my knowied lief. <br /> (11) WELL TESTS: Signed <br /> s well test made? Yes ❑ No ❑ If ves,by whom? {` (Well 'ller 1 <br /> 1 <br /> �of test Pump ❑ Bailer ❑ Air lift ❑ NAME <br /> ,h to water at start of test ft. At end of lest ft (P n or ration ( prindM) <br /> is.clharge gal/min after hours Water temperature Address <br /> y Chemical analysis made? Yes ❑ No ? CitAP <br /> ZIP <br /> y ❑ If yes,by whom. y <br /> Was electric log made Yes ❑ No ❑ If yes,attach copy to this report License No. Date of this report <br /> IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> DWR 188(REV. 12-861 86 96355 <br />