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'- )RIGINAL STATE OF CALIFORNIA Do not fiu in <br /> ` f THE RESOURCES AGENCY <br /> He with DWR <br /> DEPARTMENT OF WATER RESOURCES No, 36123 <br /> utice of Intent,No. NVATER WELL DRILLERS REPORT Stare Well No, _ <br /> Permit No. or Date other �4'e13 Nt <br /> �'L NER: (12) WELL LOG �y � <br /> tiame Total dcptlttl�,>r�tt- Depth at completed weli�lfi. <br /> ddress <br /> --A51 N- l i l l i an from ft, to ft. Formation (Describe by color, character, size or material) <br /> t, - <br /> Zip <br /> LOCATION OF, WELL (see i3stn3cti0ns}: <br /> ..nynh' an tToa L11)'1 Oµ•ner's 1\'ell\w1lber 23 sand <br /> 1! ;sddres� if differem fmm abo, 73 90 clay, <br /> :'nstnipSt 9q0 _ 101 �Cemen'te'd'- Yave1 <br /> �staarre from cities, roads, railroads, fences, etc. 101 - 105 a-Ma <br /> 105 - 108 sald'�. <br /> 108 -- 125, clay,, <br /> 125 _ 130.,.\ gravel <br /> 0) TYPE OF WORK: .130 ,E 40 . ay <br /> New Well2E Deepening 0 140 ��- 145 qravel & sang <br /> :. <br /> Rec( truntiun 0145 -- S C a <br /> Reconditioning [] - $ f] E - <br /> II <br /> Huriurntal Well ❑ - ��C' ;a-y. <br /> Destruction G (Describe - 17 6 'sand <br /> destruction materials and GaS <br /> procedures in Item 1Z)' - 180 cl:ay. <br /> (4) PROPOSED 'LTse. 180 - 194-, clay <br /> Domestic rX" 194 205 sand <br /> ]rr;�ari<,n ❑ 205 - 215 c1a <br /> Industrial \ ❑ - <br /> Test Well 1' ❑ _ <br /> Stock ]: ' <br /> �-- <br /> WELL LOCATION SKETCH Other I. [a - <br /> a I EQUIPMENT; {8) GRAY-gl- PACK: _ <br /> ;ntary lY Reverse ❑ Yes ❑ No-❑ Size <br /> able C Air ❑ = `Zi ua ter of bore d - <br /> 'r_ <br /> )they [j Bucket ❑ J�kFked from <br /> 7) CASING INSTALLED:',-- ; (8'r`PERFORAbONS: - <br /> `� <br /> >teel ❑ Plastic ❑ Cuncrets Type of petEBmtion or size of screenf::�-, - <br /> Froni Tom Dia. or F'roiri', TO Stat' <br /> ft. f� in. Wa1I ft ft. size <br /> <\ \ - <br /> 9) WELL SEAL: <br /> Was surface sanitary seat provided? Yes>] No ❑ If yes, to depth 5 Q ft, _ <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. - <br /> Siethod of semiin Work started _19 Cnmpleted lA <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water. if known - - This well vcns drilled under my jrrryredictfnn and thin report ie ince to the hest of my <br /> Standing: level after well completio fr, kvtowledge and belief. <br /> (11) WELL TESTS: SIGNED <br /> Was well test made? Yes ❑ No ❑ If yes, by wham? (Well Driller) <br /> Type of test Pump ❑ Bailer E) Air lift ❑ NAME <br /> Depth to water at start of test ft. At end of test_ ___ fr v lYrrt3, c io Ty p , <br /> Discharge_-------ga]/min after hours Water temperature Address P .0. BOX 908 <br /> Chemical analysis made? Yes ❑ Nn ❑ If vel. by whom? City—STkm. <br /> R'& tric log made? Yes � No []� IE yes, attach copy to this report License No, 200794 nate uE this report <br /> WIRIO (REV.7.76) 1F ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORMA 43036-0307-10:0M OUAD(Drozr <br />