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QUADRUPLICATE <br /> Ilse to comply with STATE OF CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY 4 <br /> 27 <br /> No. 5 <br /> DEPARTMENT OF WATER RESOURCES L r <br /> {�k N,ti a of Intent No. �r WATER WELL DRILLERS REPORT Stain well No. <br /> 4mal Permit No. or Date Other Well No. <br /> ( 1) OWNER: N,one� _�� (12) WELL LOG: Total dap 212A�ft Depth of completed ..ell_�+`fe. <br /> Address from ft. - to ft. Formation (Describe by mhu- chancter, sue or material) <br /> ( ill Monte GA- zip Top So <br /> (2) LOCATION OF WELL (Seeinstructiom): S8ndy so <br /> tonna S&A .X6a quint! 9 <br /> Owner's Well Number <br /> \fell address if different feen nhove8- 12 3&nd <br /> -1,,,,mI ip Range Sectio <br /> 12 17 "04 <br /> uu <br /> Distance from cities, roads, milraads, fences, etc. Qft OL-1 zu Between Louise In .�•�r•t Q-a <br /> G� Cla <br /> SHeIf{ fiftd. L .iana <br /> Lia nd <br /> (3) TYPE OF WORK: - L17 Clay-shale <br /> New Well g Deepening ❑ Sand <br /> Reconstruction ❑ - (� <br /> Reeonditipning ❑ 10 -11 ,3and <br /> Horizontal Well ❑ ry '1- ill Clay <br /> Destruction E] (Describe 1?- 115 Sand <br /> destruction materials and <br /> Procedures in Item 12) 115- 123 Clay <br /> (4) PROPOSED USE: - <br /> 1 Domestic [,y - <br /> trrigannn ❑ - <br /> Industrial ❑ - <br /> Test Well ❑ - <br /> Stock ❑ - <br /> Mun cipal ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRAVEL PACK: - <br /> Rotary ❑ Reverse ❑ Yes Ej No ❑ Sizeyy�q,,,-. - <br /> aeye <br /> Cable Air ❑� �_ "t,of <br /> Other ❑ Bucket [7] wed%from ,j [o. t. - <br /> (7) CASING INSTALLED (r•.\ (8�'PERFORX S: <br /> Steel ❑ Plastic s'F�l Type of PeiZ.'tinn\ri:stkL�f9lFeet�'^L - <br /> From To Dia. ttr From To Slot - <br /> ft. ff. in. Wall ft. ft. size - <br /> 96 118- <br /> I - <br /> (9) WELL SEAL: `'Was surface sanitary seal provided? Yes i, <br /> Nn ❑ If res\hr depth_t{'.t W <br /> Ho - <br /> Wen strata sealed agaiert p,dlun? Yes ❑ No ❑ Interval JJ� ft - <br /> Methral of nodue, Wnrk started !IQa 19Completed -_19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMM: <br /> Depth of first water, it known h. Thi, .11 ¢ns drdled r oder u, lu,i%duII,o and thin rrourrr o tror, In Ura hrtr at Into - <br /> Standi it level after well eonmletlo ft, kno,fedhe and hehrq. <br /> (11) WELL TESTS: 51GNED - <br /> Was well test nmde? 1'rsF No ❑ If ve,. by whom? I I\b cll Lriper) <br /> Type of test Pun", Y Baiier ❑ Air lit ❑ NAME <br /> Depth to water at start of test ft At end of test ft 4P,n, hrtn, nr cu oration ( rPet r intedl <br /> I -Tim <br /> Diecherec _galrmut after noun Water temperature Addres: 3525 <br /> Pelandale Ave* <br /> - <br /> Chemical analysis made? Yes ❑ No ❑ It y s, by whom? Ciq '! GA4Was electric log made? Yc. ❑ Noa If . :utaoh ropy to Ihis_.w'"t, e, en -N'n. Date ret this reMot <br /> OwR tee .Rey.z.zG, IF ADDITIONAL SPACE IS NEEDED. USE r X SiEIa UTIVELY NUMBERED FORM u.v.-sv.,-,,1.oc.o _.os> <br /> L I <br /> NOV '3 1977 <br /> SAN JCrnm LOCAL <br /> HEALTH DISThICT <br />