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II�� ,♦ i`r 3t� <br /> ORlGIN-AL a r STATE OF CA4tFORNIA .Do not fill In. <br /> File with DWR <br /> THE RSsaURCES AGENCY No. 216364 <br /> DEPARTMENT OF WATER RESOURCES <br /> ce of Intent No WATER WELL DRILLERS REPORT Stato Well No�_ <br /> ' other Well No. ' y f f�d <br /> al Permit No.or Dnte�d} �` C L��t, <br /> ' <br /> (I) OWNER: Nnm C t C1 (I2� WELL LOG: <br /> l Total depth-att.Depth of completed well__✓__.J{t, <br /> Address /'�' 7 fxom ft. to ft, Formation (Describe by color, character, size or mnterial)CJty f��..V.� . :{'�h:..t.�,.�`A-,. Zip O - <br /> (2) LOCATION OF INELL (See instnictions): <br /> County--�0.ri .-7Q.". nLs �� 4�L0- <br /> ner's Well Namher <br /> Wall address if different from above <br /> ' L 1 Rangec - <br /> Townshlp 1 ^fV e � ho <br /> Distanco from titles,rands,raihnads,{ones,etc. h� <br /> (3) TYPE OF WORK: <br /> ' New Wol1X Deepening 0 �^? <br /> Rccorrstructinn ❑ <br /> Recondl:forting ❑ - 'y <br /> I{orizOrtiai Well ❑ <br /> Deitructfmt p (Describe <br /> deatntetion mnterfals d <br /> an <br /> � procedur <br /> n <br /> I T es in Item ISS C <br /> ,aR (4) PROPOSEDS <br /> ' Domestic Q - .✓ ,. <br /> Irrigntion S/ <br /> Industrial �` 'L �,1� I] �.,I„-_�•f J�.��� <br /> Te{NWeli �` _ <br /> slock <br /> �n , <br /> WELL LOCATION SKETCH \�>pherlf`a <br /> ' (5) EQUIPMENT: (6) GRAVE' ACK. <br /> ' L <br /> Rotary� Reverse ❑ Tres No Size � / •�'' <br /> Cable [] Air [� tlJt dct of 6oxe r��l ��V ' <br /> Other ❑ Buckek C1 Put frdm - <br /> ' (7)CASING INSTALLED: �(R�,� {8) HRFORATIbN <br /> 'Steel Plnstic ❑ Concre�e�[�h. Type of perfoi .�ox seri of screen <br /> From To ^ -Diu. Fror�ti. `� ` )To � idt ti <br /> ' ft. ft, t, 'stn. War[ ft, ft.�y '•ti11 <br /> z� _ <br /> +' V f <br /> (8) WELL SEAL: t <br /> tiVas surface sanita:y Seal provided? Yes No ] If yes, to deptb-A1\—ft, <br /> Were strata sealed ngafnst pollulionP Yes No Interva [ <br /> ' Method of sealirt9 Work started 9 Complet 18 <br /> (14) WATER LEVELS: WELL DRILLEIi'S STATEi4IEN'T•: <br /> Depth of Rrst water, if know Thfs tach mar drilled under my {ori j on qnd th report ir true to rhe Best of meJ <br /> Standing level after well cumphti&L-.: —ft. knomtedge, arp lief. <br /> (11) WELL TESTS.r '� SIGNED <br /> ' Wa.1 well test made? Yes ❑ 'No IF y6t, by whom? ell D 'n ) ! <br /> Typo of test lump CI Bu(tor,❑ (�I <br /> Air lift❑ �1MEA\,� W <br /> .\_...���� 1 � , <br /> Depth to water at start of test--------,Ft A( end of test------ft (P o)t,firm,o on (Typed or pr at 1) <br /> rIDWR <br /> tea]/m(rt after hn�rrsS- r Water tcmperafar Address ] �+t <br /> ' naiysiv•mndc?1~de's ['} N(r If yhs,-hy whom? City c]og,sr de? 8s❑- ,jTn IF yes`itach copy to this report I icease No. � nate of i)cis repo(aEStry 7cl .,1F ADDITIONA,QSFACE 15 NEEDED. USE NEXT CONSECUTIVEI..Y NUMBERED FORM � <br /> I <br />