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ORIGINAL <br />STATE OF CALIFORNIA <br />DO not fill Ir <br />File with DWR <br />THE RESOURCES <br />AGENCY <br />DEPARTMENT OF WATER RESOURCES No <br />086088 <br />C Intent \o <br />WATER WELL DRILLERS REPORT <br />Pofenna \o or Due <br />Stite «ell No <br />Other \\ ell \o <br />1 OWNER \ Eddie <br />Ca e t= 10 <br />r <br />' n„t <br />'']] ifs Ave. <br />Address 23 6 J 0 S 1 l ua <br />(12) WELL LOG [ LLL0 <br />depth It Dtpth or <br />� <br />completed ssell�q j�it <br />Cal i't1 ion <br />• rive . <br />Ca . <br />frnm ft to ft Form ition (Deu nhe hs color c hlricter SVP nr materia 1 <br />0 <br />ZiP <br />I - To1osoi Z <br />(2) LO&MON OF NVELL (See Instrlxtloru) <br />iHa rc Dan <br />Coclmt.__'S2I1 T0ICI-11111_0« <br />ner s \4 ell Number <br />i .215 C 2V Stale <br />\l ell eddress if different From thuvt <br />1 - 3 0 Sana <br />Toss ntinip RnnLt <br />Section—_ <br />I - 1+5 S ai e <br />Distance from cities roads milmids fences etc S ,J ! 1 Tna Ave,•74n(X <br />l m7 <br />e r_or ��. of W.riT'Qn etc .. ea--t side <br />5” -62 Shale <br />162 - <br />pIe <br />(3) 'TYPE OF WORK <br />8 -05 .. V <br />Neu \N elI X Deepening 0 <br />rs ___10 <br />Rmonstrvctirin ❑ <br />A <br />1 0.-, -112 <br />1 1 2 L na <br />Retrendamnint. '1 <br />1 12 - 116 6 S) a l e <br />Honzuntal IN ell [1 <br />1 i (:� -134 cla v <br />Destrestraucinn `. (Descnbe <br />destrcritton matenals and <br />1 1 _ 1 C) Sa,.IG3 <br />prricetiures tip Item 12) <br />q <br />1 �9 _ ! YO Clay <br />(4) PROPOSED USE <br />D'omestic' xi <br />_ <br />IonLltrun 0 <br />Industriil ❑ <br />Test \Nell <br />i <br />Stuck [; <br />_ <br />municipal ❑ <br />_ <br />WELL LOCATION SKETCH Other ❑ <br />_ - <br />15) EQLIP\IEN-i <br />(6) GRAVEL PACK <br />_ <br />Ratan CK Revere ❑ <br />les X %o ❑ SizeE`77,= <br />_ <br />Cthle 7 Air ❑ <br />Diameter of burr ]i <br />- <br />Other Q Bucket 7, <br />Packed from�0 to �4 <br />f71 CASING INSTALLED <br />(8) PERFORATIONS <br />Steel ❑ Plastic ' Concrete .J <br />Tspe of perforation or size of screen <br />w <br />Froin To Dia Gale or <br />From To Slot <br />- <br />ft ft In Wall I <br />ft ft S.Ze <br />0 14 i 6 0 <br />Q8 1lL <br />rQp <br />(0) WELL SE-IL <br />Was surfice sznimi, seal provided° l es <br />_ <br />M No w If %es to depth _y.0�ft <br />- <br />strata sealed against pnllutinn° <br />les L-1 No ':Inter <br />,11e,e <br />Method of sealer Bent '' } P <br />\\ork started — 19 r!O Completes <br />-19 <br />10) WATER LEVELS <br />WELL DRILLERS STSLTEIIENT <br />Depth of hrst water if know <br />ft <br />Standmz level after cell completin <br />2 <br />Thu well u as drilled under my rurrsdictron and the cpnrr is <br />knnaledge an be(r, <br />true to the err of my <br />01 11) WELL TESTS <br />ft <br />Leu well test mndeJ Yes ❑ No)C <br />Type of test <br />If les b. whom i <br />(Well Driller) <br />Pump ❑ <br />Bailer v Air lift ❑ <br />`rAi\11r �n R r <br />r' T <br />Depth to safer Zt Start of test <br />ft At end of test ft <br />(Person firm nr enrporanon) (Typed or printed) <br />'Dnchars e��al/men free <br />Hours Water temperature <br />Address 3 52 5 pe <br />al analssrs made? Yes \o <br />If ses bs whom2 <br />Gln— Modesto, Ca. <br />Zip }?�5n <br />]ettne 1nC m tde' 1 es ❑ No <br />If yes attach cn to this report <br />ps-Date <br />License tin__220.8-1-3 of this repo <br />186 crtev �s IF ADDITIONAL <br />SPACE IS NEECED USE NEXT CONSECUTIVELY NUMBERED FORM <br />