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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 No. 250528 <br /> Notice of Intent No' <br /> r� / State Well No. <br /> Local Permit No. or Date b—/7` 1-3 Other Well No. <br /> (1) OWNER: Name (12) WELL LOG: Total depth Q� Et Completed depth Et. <br /> Address from ft to ft. Formation(Describe by color,character,size or material) <br /> City ZIP <br /> (2) LOCTIO OF WELL.(See instructions): <br /> County ,��J r Owner's Wel Num r D <br /> Well address if ferent om above <br /> Township Range Section / <br /> Distance from cities, ro ds, railroads, fences,etc. n <br /> - ao <br /> - v <br /> (3) TYPE OF WORK: <br /> New Well VDeepening ❑ <br /> Reconstruction ❑ `� <br /> Reconditioning Cl <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US _ \ <br /> Domestic <br /> Irrigation <br /> Industrial ❑ _ G <br /> Test Well O ❑ <br /> Munici 1 ❑ _ Q <br /> O er <br /> WELL LOCATION SKETCH ibe) T <br /> (5) EQUIPMENT: GRAV CK: <br /> Rotary Q/ Reverse ❑ No i <br /> Cable ❑ Air ❑ ete of bore <br /> Other ❑ Buck e c d rom�� <br /> (7) CASING INSTALLED: <br /> . (8) PER TI <br /> ORQ — <br /> Steel ❑ Plastic �n )� Ty of fo 'on or size of — <br /> Fromi Gage or t <br /> Et. Eci Wall t. size — <br /> O Soo J100 i7 <br /> PSJ - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes Cg'*' No ❑ If yes,to depth OO ft- <br /> Were strata <br /> t-Werestrata sealed against pollution? es ❑ o Cl Interval ft. <br /> Work started 19— Completed 19 <br /> Method of sealing <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 t <br /> Standing level after well completion ft. hest of my knowledge and belief. <br /> (11) WELL TESTS: Signed e11Driler) <br /> Was well test made? Yes ❑ No ❑ If yes,by whom? <br /> Type of test Pump ❑ Bailer Cl Air lift ❑ NAME <br /> At end of test Et. � ( rson,E' co ration)(Ty or printed) <br /> Depth to water at start of test It. O <br /> Address <br /> Discharge gal/min after hours Water temperature <br /> ZIP <br /> Chemical analysis made? Yes C1No El if yes,by whom? City <br /> Was electric log made Yes ❑ No ❑ If yes,attach copy to this report License No. <br /> Date of this report <br /> IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 96 96333 <br /> DWR 188(REV. 12-88) <br />