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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 225246 <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State Well No �/r- <br /> Local Permit No. or Dale Other Well No.O!! 00T'G :3,0 <br /> (1) OWNER: Name Aruthur Kemal an (12) WELL LOG: Total depth 200 . Depth of completed well 200 R. <br /> Address 5528 E: Acampo Rd* form k. to ft Formation (Describe by colo, characte, rice or mamrfal) <br /> City AcampoqGi p0 - 5 grey clay <br /> L IQ9911nWELL (Se instructions): n clay <br /> County r's Well Number 30 _ 70 . <br /> b cls <br /> Well address if different from above 5530 B Acampo Rd. 70 - 130 sand.wAer <br /> Township Acampo nge sectio4Dcepenin7go <br /> 130 - 135 brn cla <br /> Distance from cities,roads, railroads,fences, etc. 135 — 18O safi6 water <br /> 180 - 190 brn\ <br /> 190 - 20 sand ater <br /> (3) T <br /> New W <br /> Reconstruction ❑ — <br /> Reconditioning ❑ — <br /> H.Ai octal Well ❑ <br /> Destruction ❑ (Describe — <br /> destruction materials <br /> procedures in Item 1 — <br /> (4) PROPOSED — (31 <br /> Domestic — <br /> Irrigation ❑ <br /> Industrial O ❑ — <br /> T SS\\��\\Well C3 — <br /> Sh�d2�\ — <br /> Munfcipa <br /> WELL LOCATION SKETCH er ❑ — -1, <br /> (5) EQUIPMENT: (8) CRAVELACK: — F <br /> Rotary ❑ Reverse ❑ lCp)S❑ No\\ Sia �l• <br /> Cable JV Air ❑ .Tar of bore <br /> Other ❑ Bucket ❑ Pec o — <br /> (7) CASING INSTALLED: (8) ERFORA'Pfb — <br /> Steel Qs Plastic ❑ Covc a Type of rats or of screen From To Dia. Ga F To <br /> fr. ft Jin. <br /> Wal 1 fft size — <br /> 0 185 � 12 - <br /> <� \ - <br /> (9) WELL SEAL: V�Was surface sanitary seal provided? Yes30 No ❑ If yes, to depth 55 - <br /> Were strata sealed against pollution? Yes ❑ No Interval e, - <br /> 6 3 96 613-86 <br /> Method of se Work st.,ted - 1Y_ Completed 19_ <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of fist wale; If k>ww, 80 R no ledg lase drilled under my jurvdiction and this report is true. of my <br /> Standing level Aker well completion e/() ft, knowledge and belief. <br /> (11) WELL TESTS: SICNED woods Well Drillin <br /> Was well test made? Yes ❑ No 30,If yes, by whom? (Well Driller) <br /> Type of test Pump ❑ Bauer ❑ Air lift ❑ NAME 11944 Simmerhorn Rd. <br /> Depth to water at start of test k. At ead of t t ft (Persoq firm or pontion �L Typed or printed) <br /> Ducharga gal/min after hours Water tempera Address Ga1t�Caii or956 _ <br /> Chemical analysis made? Yes ❑ No ❑ If yes, by whom? Csry' 9 <br /> Was electric log made? Yes ❑ No ❑ If yes, attach copy to this report Lice.No 282866 Data of this repot ".16-86 <br /> DWR 188 (REV.].76) 1 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />