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' J STATE OF CAUFORNIA <br /> ORIGINAL THE RESOURCES AGENCY DO not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT N0. 287009 <br /> tice of Intent No �C{{� ) r� State Well Na <br /> al Permit No or Dale `�_ ��A f+/' / Other Well No�s <br /> fAddress OWNER Name (12) WELL LOG Total depth /.2D ft Completed depth Z&i ft <br /> - <br /> from ft to ft Formation (Describe by color character size or material) <br /> City ZIP , <br /> _ t <br /> ' (2) LO ,ATION OF WELL (See instructions) <br /> C oulkly ' 1 ( Owner s Well Nyrs4ber <br /> Wt It address if differt nt fr_ory abov -- - - <br /> ' Township 0r/ Range Section ' <br /> Distinct frurn cities,roads railroads, fences,etc <br /> (3) TYPE OF WORK - <br /> C New Well 4a. Deepening ❑ zar ` <br /> ' Reconstruction ❑ ' <br /> Reconditioning ❑ 7 I _ r <br /> Horizontal Well ❑ <br /> ' w r Destruction ❑ (Describe - <br /> y destruction materials and pro <br /> cedures in Item 12) <br /> (4) PROPOSED US _ <br /> Domestic _ <br /> Irrigation <br /> Industrial O ❑ _ r <br /> Test Well ❑ a <br /> .CC�1c�� Munict © O <br /> _ O er _ <br /> N I•I I l IX AT1ON 9*LT(H e ibe.) <br /> ' (5) EQUIPMENT tcA, CK - <br /> Rotiry 01 Reverse ❑ No SI <br /> l�ble ❑ Air ❑ of bore <br /> 01 her [3Ruck from A <br /> (7) CASING INSTALLED (8) Pi TI _ <br /> Steel ❑ m Tt 1 of l nn ur stn„f r� <br /> ' From D Gage or ,t - <br /> ft f Wall t size <br /> (9) WELL SEAL +— <br /> ' Was surface sanitary seal provided? Yes DI No ❑ if 1 es to depth- �-dC' I I <br /> Were slratasealedagairwpollution;, Yes ❑ No to Intenal It g '� <br /> M.Ilrttfst rhnti 1 1 ! 1\ r 1 I~ r�-� IL - L `t :I _J-� ilr <br /> (10) W TER LEVELS 1i 1 i 1 1 tall I.1 Its ,1 % 11 11F \ 1 ' - <br />' 114 tali,i lrni wait r if krxtrn <br /> ri <br /> titer.Sur�Iralafl.rrrllttlttly,letieun ___ _ i r, r i tt��r � � �'•• >''s 'r r's� S , stir <br /> till 11111 111115 <br /> .•11 t r.t rr i.k' 1 n � ) ♦, t� 11. . I. �r . _ _ • r i.r,a..f T�(,. V� + �� � r`_!` <br /> '. a 1 J f„nil, I } Is.L r s.. Ur i �.1 l: ��.• lr.. � t � �' t �� <br /> t 51 - <br /> �4A.1 0 ,.1 Jw.[ /IN II \l.,.1 , i � ! � «.• ♦`,M /+..wry <br /> ...rt �-,_ (Il u•u•♦Ilii 1..,, HN ,..w.�-.M.r. _,_ \ 1 �``�' ♦ ���L _ <br /> t.•• ... � ..v 1n \ ` 11 ti 1 .• ... _- 1 � ��� -_ X11 �� J <br /> .. , r ..: I ♦ -s� l� ! �� Ei.l. t liu•,r .rt r! d <br /> r <br /> •F wDQ,TsdrAs. }awCl !S Afi!EQE]] USE NEXT COesSECUT'!VF-LY NUMBERED FORM <br />' 66 1w1]S <br />