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' ORIGINAL STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY DO not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 374930 <br /> Notice of Intent No :2 5 State Well No <br /> .ocal Permit No or Date Other Well No — <br /> (1) OWNER Name (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 <br /> (2) LOCAT O ^OF WELL (See Instructions) L <br /> County ~_�12"j Owners Well Number <br />' Well address if different from above <br /> Township Range Section <br /> Distance from cities,roads railroads,fences,etc <br /> - <br /> CsRA1d]— I,'>✓,4- (3) TYPE OF WORK /J <br />' New Well X Deepening ❑ <br /> Reconstruction ❑ <br /> pr <br /> �4! r �N^r /,,-� Reconditioning ❑ = <br /> !3` / Horizontal Well C1 <br /> Destruction ❑ (Describe <br />' / I destruction materials and pro- <br /> � cedures in[tem 12) � <br /> 1 <br />' <br /> (4) PROPOSED USE/,` <br /> Domestic \Ej <br /> 4 <br /> Irrigation Q <br /> Industrial �� ❑ ���� <br /> /r <br /> Test Well �` ❑ '�,\�,� <br /> Municipal • ❑ �� \� `✓ <br />' WELL LOCATION SKETCH ihe) <br /> (5) EQUIPMENT GRAY CK <br /> Rotary E3 Reverse ❑ No © Si <br /> Cable ❑ Air et of bore1\— <br />' Other Off Ruck e Pa ed rom a \to — <br /> V <br /> (7) CASING INSTALLS (8) PER ORATIONS <br /> ' steel El Plastic 91 T4� y of "-oration of size of screen, _ <br /> From 1b, Gage or `M To�f� C jSlot <br /> ft f Wall fi>> -,ft' size — <br /> 71 <br /> (9) WELL SEAL — <br /> Was surface sanitary seal provided? Yes]ff No ❑ If yes,to depth 40, _ft = <br /> Were strata sealed against pollution? Yes © No ❑ Interval / It <br /> Method of sealing Work started 19 Completed 19 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water if known it <br /> This we![ S)dralled under m diction itd this report is true to the <br /> Standing level after well completion ft best ofrn741 wledge and be(11) WELL TESTS St ned ��� �Gl <br />' Was well test made? Yes ❑ No If yes by whom? $ t W <br /> ( el <br /> F-1l Dnl <br /> Type of test Pump ❑ Bailer ❑ Air lift NAME <br /> Depth to water at start of test It At end of test ft f� ( erson ftrtn ration ( or print ) <br /> Discharge gak/mm after hours Water tempo W"re Address/ / <br /> Chemical analysis made? Yes M No ❑ If yes,by whom City <br /> Was electric log made Yes ❑ No If yes attach copy to this port License No 1 Date of this report <br /> DWR tee(Rev 12.84) 1F ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM Z 96355 <br />