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I <br /> A 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. 374929 <br /> _ <br /> lNotice of Intent No 1' � State Well No <br /> Local Permit No or Date 00 Other Well No <br /> I <br /> (1) OWNER Name f 5 (12) WELL LOG Total depth ft Completed depth ft <br /> Address from ft to ft Formation (Describe by color character size or material) <br />' city ZIP/22:,2 a- _ �/ r Ic— <br /> r <br /> _ - S r—Z <br /> (2) LO�C--ATIO OF W�E�`'L (See instructions) <br /> County_ Owners Welt Ntfmber- �~ <br /> Well address if different from above) �� <br />' Township Range Section = <br /> Distance from titles,roads,railroads fences,etc <br /> AfP 4l� — <br /> z- <br /> .4 <br /> r µr12 <br /> ! <br /> OWA,dUT X, �e�� (3) TYPE OF WORT{ — <br />' / New Well 04 Deepening ❑ _ <br /> IReconstruction ❑ <br /> Reconditioning � <br /> Horizontal Well ❑ <br /> � w Destruction ❑ (Describe — <br /> &v �� � �A4 destruction materials and pro- <br /> cedures in Item 12) J <br /> (4) PROPOSED USEf <br /> Domestic — <br /> / I�N Irrigation I] <br /> f\ `� Industrial X ❑ ��— <br /> \ 11tl Test Well \� ❑ <br /> WELL LOCATION SKETCH ibe) <br /> (5) EQUIPMENT GRAY CK <br /> Rotary ❑ Reverse ❑ No <br /> Cable ❑ Air ❑ et of bore 1 <br />' Other til Bucke ed rom to_Zr'7 <br /> (7) CASING INSTALLED V (8) PERPOkATIONS — <br /> ' steel El plague 119 Ty of foon or size of scteeii�� — <br /> From T I Gage or �lSlOt — <br /> ft f t Wall \ � ft size <br /> (9) WELL SEAL — <br /> Was surface sanitary seal provided? Yes f'd' No ❑ If yes to depth_ it = <br /> Were strata sealed against pollution? Yes ❑ No ❑ Interval It <br /> Method of sealing Work started. L.:-,f —19 Completed 19 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> ' Depth of first water if known ft <br /> This well was drilled under m urtsdsstevn and t report is true to the <br /> Standing level after well completion ft best of mf ledge dd belt <br /> (11) WELL TESTS Signed �'L <br /> ' Was well test made? Yes ❑ No N If yes,by whom? Driller <br /> Type of test Pump El Railer ❑ Air lift ElNAM l r ✓r <br /> Depth to water at start of test Ei At end of test It �.{P�raoir fi torpor tion)(Typed or nn <br /> L7ischarge gal/minafter hours Water emperature Addr <br /> 7 <br /> Chemical analysis made? Yes Z No ❑ IE yes by wham?� r City ZIP <br /> Was electric log made Yes ❑ No ® If yes,attach copy to this r port License No Date of this report <br /> DWR 188 (REV 12-aa) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />