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STATE OF CALIFORNIA Do flet fill in <br /> ORI{_,7INQL <br /> ' THE RESOURCES AGENCY 16 No. 216365 3 Q i) <br /> C <br /> File vvit4 DWR DEPARTMENT OF WATER' RESOURCES 'yV L O <br /> ice of Intent No, 'WATER WELL DEMLERS REPORT state welt No <br /> ' al Pe,�•Jt No,or Date <? � <br /> M <br /> Other Wall No 6f =� <br /> A <br /> I <br /> (1) OWNER: Nan, (72) WELL LOG: Total dap it.Depth of complatod Wel t. <br /> Addressfrom ft. to ft. Formation (Describe by color, charnctnr, size or material <br /> City z ip � Y <br /> (2) LOCATION OF WELL,(see instructions),. _ <br /> County_.561!�_3 a Owner's Well Itiumbet - <br /> Well address If different from nbov <br /> IS krl <br /> Tnwmhip•_, 'r���. - Hnn((c � actio <br /> Dlstnnee from cities,roads,xniirnads,fences,etc. <br /> N) <br /> P) 11ML <br /> OF WORK: � <br /> New WeLIX0 Deepening[I <br /> ' Recamtructlon ❑ <br /> Reconditloning Q �' e <br /> Horizontal Well <br /> Destruction ❑ (Describe <br /> destruction mntoriols � IV <br /> Procedures in Item 12,51,e- r� <br /> (4) PROPOSED l7X� —OIL, r <br /> /l Irrigation <br /> VV IndustrenL ❑ � (^r � y <br /> e <br /> Tes - elE <br /> ! <br /> !Municipal ❑ � - n � <br /> 1VEI L I OC,tiTI0i2 SICETCII 'ether ^ -� <br /> (5) GQUIPbtEN7i (11) GHA4rEL`PA_CiC: „ <br /> Ilatnry Reverse {] No 0 _ <br /> Cable ❑ Air 0 �'DVlEk of bore <br /> Other Q Bucket 0 Pn�c] - <br /> (7) CASING INSTALLEn. <br /> Steel Plastic ❑ Cnncr't C} Type of perfnld b [91zd aE scrEan <br /> IIo►n <br /> To ^Dia. Gni ilor Fronts <br /> in. Wall ft. •= ft <br /> 7 <br /> 10 <br /> F <br /> (0) WELL WALLt <br /> Wax surface sanitary goal pxoitided?_ Yes �rNo'�) If yes, to dept (t. <br /> wore strata realed agalnsE,•p'nllutlaxiR'YPy y "';�%Dr� <br /> b�p Interya Et. - <br /> ' Methad of scalin r Work start r l$ Complete S <br /> (10) WATEA LEvl1LS�: �. at. ; WELL DR]LLEWS STATEMENT: <br /> Depth aE first wntpi•it knnty k ft This well Teri drit(ed under mfr inri IPt'on nor!ih' apart (a+rlre to the Gert of m1 <br /> Standing lave! nfte,FVeI <br /> CO <br /> b % [t, knowfedge c el f. <br /> ' (Il) WELL T STSI1 Slcrrrn <br /> ,« <br /> Was well test tnnde Yes f� '''Nd ^If Ye71n <br /> l D'elle r <br /> Type of test bmp" Bjr9(eAir lift(] 'NAil(E C <br /> Depth to water at sta F}Sas r'+' ft:'r f test ft ( L: �Ua�t <br /> rpo tion) (Fyped pr priri ) <br /> isehaxgn <br /> 4,h'7 Pius' Water temperature Address <br /> t , t t ;P, z;mlril nnnlysls made? Yes'b•...,,{+�?t� : IP'�r, try whom? Cry - �� re or s e]ectria loft mndc? Yex[� NoIE res, attack copy to this report License No. p <br /> PWR 180 (REV.7.7e) IF ADD ITIoNAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM � <br />