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�,�FrOR[ViA 1 <br /> QUADRUPLICATE RESOURCES ANCA! Do not fill in <br /> Use to comply with DEPA MENT OF WATER R OURCES oo <br /> local requirements WATER V M ERS REPORT N0. 250528 <br /> Notice of Intent No. ENVIROMFN T AL HEALTH State Well No. <br /> Local Permit No.or Date J F RMIT Other Well No. <br /> (1) OWNER: Name LGG9r_ 2 '- ?/ (12) WELL LOG: Total depth ft.Completed depth ft. <br /> Address r from ft to ft Formation(Describe by color,character,size or material) <br /> City ZIP <br /> (2) LOCATION OF WELL (See instructions): <br /> County ' '' Owner's Well Number <br /> Well address if different from above F %'�'" 9l i — ! 4/ <br /> Township Range' Section y <br /> Distance from cities,rodds,railroads,fences,etc. i <br /> n <br /> r: <br /> (3) TYPE OF WORK: — i _r ,, •,_, , <br /> New Well W Deepening ❑ <br /> Reconstruction ❑ y�(' <br /> Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US _ <br /> Domestic r _ <br /> Irrigation <br /> Industrial O ❑ <br /> Well El _ <br /> Test Wela <br /> Munici El _ 0 <br /> O er <br /> WELL LOCATION SKETCH < <br /> (5) EQUIPMENT: tOG <br /> A'I ( CK: <br /> Rotary �]•" Reverse ❑ No\ Si <br /> Cable ❑ Air ❑Other ❑ Bucke from <br /> (7) CASING INSTALLED: (8) PE ATI O — <br /> Steel El Plastic an e Ty of fo 'on or size of _ <br /> From o D' Gage or of — <br /> ft. f t Wall t. size — <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes (11" No ❑ If yes,to depth Z" Ft Were strata sealed against pollution? Yes 0__—No ❑ Interval ft. — <br /> Method of sealing Work started 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 my jurisdiction and this report is true to the <br /> Standing level after well completion ft- best of my knowledge and belief. <br /> (11) WELL TESTS: Signed 2 <br /> Was well test made? Yes ❑ No ❑ If yes,by whom? .(Well Driller) <br /> Type of test Pump <br /> ❑ Bailer ❑ Air I(Et ❑ NAME <br /> Depth to water at start of test ft. At end of test (t. (Person,firr¢.9r corporation)(Typed or printed) <br /> Address ' <br /> Discharge gal/min after hours Water temperature _ <br /> Chemical analysis made? Yes ❑ No ❑ If yes,by whom? City Y " ZIP <br /> Was electric log made Yes ❑ No ❑ If yes,attach copy to this report License No. '` Date of this report <br /> IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br /> DWR 188 (REV. 12-86) <br />