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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> Pile with DWR <br /> THE RESOURCES AGENCY <br /> DPNo. 36176 <br /> DEPARTMENT OF WATER RESOURCES <br /> fNotice of Intent N WATER WELL DRILLERS REPORT State Wall No. <br /> 1 - rot Pr .nit No. or Data Other {Yell N4 <br /> 4 Z C�L_ <br /> ( 12) WELL LOG: Total dept* L Depth of completed <br /> Address 1051 N _ Al rnnrt Flag from R, to ft. Formation ( Describe by "lot, ehatecter, rise or meteriat) <br /> Crty C+ nnir+ nn f!alastR�,Z+niR y)p. <br /> (2 ) LOCATION OF WELL ( see instnictiorts ) : 110 1111 0031rae sand & gravel mrock <br /> Cnuuty Cin �i ll Ownees Well Number 1 3P <br /> Well address if different from ibo 2 - 134 q "bnlnv <br /> Townshin pang coctio134 UO <br /> = <br /> Distance from cines, mads, railroads, fencaur, at <br /> j (3) TYPE OF WORK: <br /> i <br /> New Well ❑ Deepening <br /> Reconstruction ❑ - t � � <br /> Reconditioning ❑ - �+' fy <br /> Horizontal Wail - <br /> - , <br /> Destruction <br /> estr ction materials�criha h <br /> Procedures in Item <br /> C a <br /> ( 4 ) PROPOSED � -_ Z'l N' <br /> Dc ncut(c rh <br /> In ustsda 1 V <br /> Indutdl � ❑ <br /> furan / ❑ ` � <br /> -� - WELL LOCATION SKETCH Other ❑ ,✓ <br /> ( 5) EQUIPMENTS ( 9) CBA � PACKr <br /> f Ilwary 2 Aevena ❑ No <br /> Coble ❑ Ah ❑ ren of bar <br /> 1 i <br /> Other ❑ Bucket ❑ � gyne <br /> (9) CASING INSTALLEDp' (Sj'�PEAFORA'7'kn 1�5: - <br /> Stool El Plastic ❑ Cry et Type of perl�i be of ameeg,r� <br /> FromT_q.-. Dia. G9g9r F�o� To 30 — <br /> ft, fY in. Wall f \ ft si, — <br /> v _ <br /> ( 0 ) WELL SEAL: - — <br /> War surface sanitary seal provided? Yes ❑ No ❑ If yes, to depth ft. <br /> Were strum sealed Against pollution? Yes ❑ No ❑ Imervel n, <br /> Method of seadinar Work stated 19_ Completed_ 19_ <br /> ( 10 ) WATER LEVELS: WELL DRILLEWS STATEbfENT: <br /> Depth of first water, if known This well was drilled Under mg furkdectlon and this report Is true to the best of my <br /> Standing level after well LompietinD p, knowledge and belief. <br /> ( 11 ) WELL TESTS : SIGNED <br /> Was well test made? Yes ❑ No ❑ If year by whmn? (Wall Driller) <br /> Type of test Damp ❑ Beller ❑ Air Bft ❑ NAME Val tOk Z Rte " T�� <br /> Depth to water at stir[ of test ft. At end of test w (Person, fine, rpnmtion ) (Typedpn a) <br /> Dbcharge gel/min akar bolus Water tempemtuY Addrese <br /> non <br /> Chemical analysis made? Yes ❑ No ❑ 7f yes, by whom2 Cib�S iovl{c-(" r611:2T B���B r> '—gip <br /> Qkdgg&WC log made? Yes ❑ No ❑ If yes, Attach copy to this report License xo ate of this report <br /> (rev. 7,70) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM srma-eso 7.76 500 QUAD Gb ear <br />