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QUADRUPLICATE <br /> Use to comply with STATE OF CALIFORNIA Do not fill in <br /> local reduir6ments THE RESOURCES AGENCY No. 2 4 5 8 8 <br /> DEPARTMENT OF WATER RESOURCES <br /> Nqi e of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> L¢a]Pernot No. or Date 77—.T,22?WI11 Other Well No-- <br /> ( <br /> o _( I) OWNER: Name A I ftoeeh4 n 1 (12) WELL LOG: Total depth-121L ft. Depth of olapltted weu-33n ft. <br /> Address from ft. to ft. Formation (Describe+?}{ mloq eharaeter' size or arah mal))_ <br /> i inRipens Calif. zip 0-a3 Send <br /> ` (2) LOCATION OF WELL (see instructions): 9 Clay <br /> { Loaray Safi JM joaquiaOwner's Well NumberSand <br /> 1 l\'ell address if different from shore <br /> Township Sectinn <br /> Distance from cities,roads, railroads, fenees,etc. Airport Way ;n . P, n1ny <br /> Clay <br /> 99-�92 sand <br /> (3) TYPE OF WORK: Clay be I db <br /> New Well i Deepening ❑ <br /> ReconsWctinn ❑ - <br /> Reconditioning ❑ - <br /> Sand <br /> Horizontal Well ❑ - <br /> n <br />`1 Destmction ❑ (Desedhe <br /> f destruction materials and Snad <br /> pmeedures-in Item li) - <br /> Glay <br /> (4) PROPOSED USE: <br /> Domestic ❑ <br /> 226 229 Clay <br /> Irrigation g - <br /> Industrlal ❑ 2�9--265 Sand <br /> Test Well Cl 265-a-280 srnd 41 gravel <br /> S' k ❑ <br /> '?t Blue Clay <br /> Monieipal ❑ <br /> Blue Sand <br /> WELL LOCATION SKETCH Other ❑ <br /> (5) EQuIPMENT: (R) GRAVEL PACK: - <br /> R a., ❑ Reverse YesX] No ❑ Size - <br /> Cable ❑ Air ❑ Diameter of h.,-----26a - <br /> Other ❑ Rucket ❑ Pack d from hf L - <br /> (7) CASING INSTALLED: (S) PERFORATIONS: louvered <br /> Steel Plastic ❑ Concrete ❑ Type of perforation nr sizeof semen 4 - <br /> Frani To Dia. Cago or From To Slot - <br /> ft. ft. in. Wall ft. ft. size <br /> - 1 <br /> - i <br /> (9) WELL SEAL: <br /> i Was surface sanitary seal provided? Yes jk No ❑ It yes, to depth--%—ft. _ <br /> Were strata sealed against pollution? Yes ❑ No ❑ InterVa R. <br /> t Method of sealfn. Work started 19 ComPlet. lll_ <br /> i (10) WATER LEVELS: WELL DRIL STATE NT: I <br /> j Depth of first water, it known ft. This well wax drilfed uad.. o,o io,odu:h.,n and no, repos i,, tme a the best of npr <br /> Standing level after well c onnletion ft. krooaledge and helaf. <br /> (11) WELL TESTS: SA:\tll <br /> Was well test nude? 1-esy� No G If res, to why o? .t'eil Dnlh r) <br /> Type of test Pun,E, Nailer ❑ NA\rF <br /> Depth to water at start nl tx___.tt At end of test tt • <br /> Discharge_ nl1min afle.rhours Nater tempamhme .Wdrvss <br /> j'.f...���/L�/ "idau AV • <br /> Chernk oaafvefs made? 1'e, l: No - Ik ves, by whnmt Cip-- ls}-�—ry•-��-{.� <br /> Was electric log made? Tes fl So If ces,attach uopy to this report License No. Onte of this report <br /> DWR IBe .REV. 7ne, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM sou.... ose <br /> k <br />