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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 374928 <br /> ,Notice of Intent No � 7 y State Well No <br /> I ocal Permit No or Date (J Other Well No <br /> (1) OWNER Name � � �y (12) WELL LOG Total depthc&&ft Completed depth z5Z —ft <br /> Address from ft to ft Formation(Describe by color character size or material) <br /> City G? 71P <br /> (2) LOCATION OF WELL (See Instructions) r � � S/L � <br /> County_—?' �C �i7 � �+ Owners Well Number <br /> Well address if different from <br />' Township flange Section — <br /> Distance from cities roads,railroads fences etc <br /> (3) TYPE OF WORK _ <br /> New Well JK Deepening ❑ — <br /> Reconstruction ❑ — n <br /> Reconditioning ❑ _"^ <br /> jib 1 , Horizontal Well ❑ <br /> Destruction 0 (Describe — <br /> / , destruction materials and pro- <br /> cedures in Item 12) \\� <br /> (4) PROPOSED US _ <br />' GIQAY7 /A4 Domestic _ <br /> �/ w Irrigation <br /> VIndustrial ❑ _ <br /> Q Test Well O ❑ <br /> Munici ❑ <br /> O er <br /> WELL LOCATION SKETCH <br /> (5) EQUIPMENT GRA CK / <br /> $;�� <br /> Rotary ❑ Reverse ❑ No Slee <br />' Cable ❑ Air ❑ et of bare u <br /> Other 0 Buck a rom <br /> (7) CASING INSTALLEa (8) PERFORATIONS <br /> Steel ❑ Plastic (,$ Ty ofo on m size of Q From I Cage or <br /> ft f Wall �),ze _ <br /> (9) WELL SEAL - <br />' Was surface sanitary seal provided? Yes ® No ❑ If yes,to depth_ _�7 ft = <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval ft <br /> Method ofsealing Work started 19 Com leted I9 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br />' Depth of first water if known ft <br /> Standing level after well completion ft best est well was drilled under my fur ¢"'on nd this r tis true to the <br /> of my� edge and belie <br />' (11) WELL TESTS Signed <br /> Was well teat made? Yes ❑ No If yes,by whom? r (W er) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME <br /> Depth to water at startof test ft At end of test ft erson firm co rate )(Typed ) <br /> Discharge gal/min after hours Water tempe ature Address <br /> Chemical analysis trade? Yes ® No ❑ If yes by whom> City ' ZIP <br /> Was <br /> Was electric made Yes ElN <br /> No 3 If yes,attach copy to th report License o — 0 Date of this report <br /> DWR 108 IREV 12.86) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96353 <br />