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M' <br /> y STATE OF CALIFORNIA <br /> 0 MAL � � THE RESOURCES AGENCY Do not fill in <br /> Fi)@_with ©wR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 319625 <br /> Iotice of Intent No. state Well No. <br /> Local Permit No.or Date Other Well No. 04Q <br /> (1) OWNER. Mame 8�>I (12) WELL LOG: Total depth ft.Cornpleted depth ft. <br /> ' Address i� �' from ft. to It. Formation(Describe by color,character,size or material) <br /> City S�tI7G C' ZIP 9524 <br /> (2) LOCkTJOOF WELL' f(See instructions); — <br /> County S:JOa' ivner's Wellumber <br /> Well address If different from above <br /> Township Range Section — <br /> ' Distance from cilles,roads,rnilroad%fences,etc <br /> ' (3) TYPE OF WORK: ^ <br /> Now Well �r Deepening ❑ <br /> Reconstruction ❑ <br /> ' Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ (1)escribe <br /> destruction materials and pro- <br /> S'ee. a +7,r- cednres in Item 12) <br /> (4) PROPOSED U _ <br /> (J Domestic <br /> Irrigntion <br /> Industrial ❑ _ <br /> Test 4Ve11 ❑ <br /> Munici V ❑ — <br /> O er _ <br /> ' WELL LOCATION SKCPCfj <br /> (5) EQUIPMENT: S�CRAV tCK: <br /> Rosary ElReverser ❑ No SI <br /> ' <br /> Cable ❑ Air ❑ � I?i, et rtioE lwre _ <br /> (Aber ❑ Bucks ❑ Iia�eddrrona F — <br /> (7) CASINC IHSTALLX-J)c (8) PERgf%.A1Tlon <br /> I e <br /> ' Stec! ❑ P1aslie n rat T of or size of �/ = <br /> From Di . Cage or lot <br /> ft [ iI. Will t size — <br /> (9) WELL SEAL: <br /> ' Was sarfacesonitary seal provided? Yes ❑ No❑ ffyes,todepth ft, <br /> Werestmiasmiedagalrrstpollution? Yes[3 No❑ intervat ft. <br /> Methodafsealing Work started 19— Completed 19— <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT. <br /> Depth of first water,it known j ft. This well was drilled under a furisdicllon and iftfs report is true to the <br /> Standing level after well completion _./-01217 ft. best of MtoialCdga and belts. <br /> (11) WELL TESTS: SI nett r <br /> Was well test mado? Yes [] No� If yes,by wham? $ (Vti Il DrII! r) <br /> ' Type of test Pump El Boller 13 Air lift ❑ NANI V ' r 5�1t PL! <br /> Depth to water al start of test ft. At end of test ft. J_�er n, M.or orpar ion (Type or printed) <br /> Discharge gal/minaRcr bora Water temperature Addre �� f�9 � �� �t P1 <br /> Chemical analysis made? Yes ❑ No Q If yes,by whom? City x Zip t. ' <br /> Was electric lag made Yes ❑ t4ro 0 If yc5�attachccpy to th1srcport Litense No. J Date of tills report l <br /> Lnai <br /> DWn 1158(REY. 12-1313) IF A1701'r1ONAL SPACE IS NEEDED. USE NEXT CONSECVTIVELY NUMEIERED FORM s wb3s3 <br />