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OR1611E' (!! STATE OF CALIFORMA Do not i�in <br /> f THE RESOURCES AGENCY <br /> File with j`*R DEPARTMENT OF WATER RESOURCES 'Vo. X19/7 6y��}1 �7 <br /> ties of Intent Nn WATER WELL DRMLERS REPORT State tYe11 No s0��4/f( �V�l1�Gr <br /> t --- tint No.or Data <br /> Other Well No <br /> (1) OWNER. Nath Ct (12) WELL LOG, Tata]depth _ft.Depth of completed well_ft. <br /> Addrest Mtzfrom fL to fL Formation (Describe by color, churucter, sire or material) <br /> ' City Zi,91 ` <br /> (2) L CATION OF WELL (See instructions):: ~2,*AA5,G <br /> County �I a Ownees Wel]Number — n <br /> ' Well arldress it different:From abs :r Y _ W N A ' <br /> Totrnship ansa—�zr ectia " I <br /> Distance from cttiea, mads,wilmads,fences,etc =�l,�, V A <br /> (3 cm 064E--1ex6a m <br /> D atreto�E'ld aryl <br /> (3) TYPE'. OF WORK: <br /> ' New 1VZN1 Deepening[] �,� <br /> V)12 �1"7�-i'.�—�••�•�. <br /> Reconstruction ❑ _ 3 4q = 5� I to r ��� OTH <br /> 62-y� <br /> Reeanditioning ❑ �� 3L� i— !7a'uQra � rTt <br /> Hotizantal Wel! <br /> ' <br /> Destruction Q (Describe t �,^ 1, <br /> ( f (J destruction materials asfd ,1 R �f�(�i !�/y Q��Q����/��fir•{ <br /> J ( `J a asroceduies in item 1� ,1 v = Z I Q ��a�a!✓ Q <br /> e �^ (4) YROPOSED OSE✓\ \�_R ` <br /> ' Damesttc �}'• <br /> 1 C f) 1 <br /> Irrigation 13ti <br /> t'l Industrial \ �/ ❑ ��}�-�/ \\` r <br /> gob <br /> St <br /> \ \ <br /> WELT, LOCATION SKETCH �\,� Other KOhtl%-.Rrlk <br /> (5) EQUIPMENT: <br /> ' Rotary Reverse ❑ 1(esj No r1 <br /> Cable [) Air ❑ j1y,meter of bore ` t <br /> 01her 0 Bucket ❑ pa�7ced`from `��} <br /> (7) CASINC INSTALLED: C-.\C3\ {$} g>wRFOff}G{TIQ <br /> Steel © Plastin © Co c[ate � Type of ptrtgranon or size of scree-I <br /> From Tor Dia. Gage ar FI \ To <br /> ' fL fL, wall #t.r\ ft <br /> ' (9) WELL SEAL: ��Y ' 1art...GM <br /> %Vas surface sanitary seal provided? Yes No ❑ IE yes, to depth - ft. <br /> r <br /> %Vere strata <br /> ' scaled nnin 0 <br /> hietbod of seallpd ElhIntervn�ft. — <br /> `York started m ,19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first tinter, if kno ft. Phis well drtlied under my jurfrdietfon and this report is trite to the bort of my <br /> Standing level after well mnipletio it. knowledKe nd bciief. J,��,, <br /> (11) WELT. 'TESTS: SirNEM �ftac_� .1�Wru well test male? Yes"d] No 0 If yes, 1iy whomL (We11 Driller) <br /> Type of test Pump-JA llaiier C) Air lift❑ NAME i <br /> Depth to water at start of text_._____�IL At end of test_------Jt (Person firm,or enrpomtion) (Typed nr printed) <br /> Discharge - nnE/trio nEter hone Wafer tempernturc IL <br /> r Address �Y <br /> ' Chr ono] itis made? Yes No �i ILI, Ci <br /> y � ❑ If ypa, by whom? <br /> tYa�iric!ofi made? Yes No [j If yes,atinch copy to this repot! License No. nate of this repo tt <br /> WR tee {p[v7.751 IF ADDITIONAL SPACE SS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />