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ORIGINAL <br />He with DWR <br />a of Intent No <br />+ Permit NO or Date <br />STATE OF CALIFORNIA <br />THE RESOURCES AGENCY <br />DEPARTMENT OF WATER RESOURCES <br />WATER WELL DRILLERS REPORT <br />'7r OWNER \ ime_.. E -y r r i- <br />Address 2 33 7:7 1 <br />City 0�1 p �a i Zf .zip o 52_ <br />(2) LOCATION OF WELL ( See lnstructlorts ) <br />Coonty -Jan-b3 <br />b3 ll In Owners \'� efl Number <br />«ell iddress if dvflLrent from lbove <br />t To-nship Ranee Section <br />Distance from cines roads railroads fences etc 2 341° 1Lma <br />Do not fill lI <br />No, 097921° <br />State Well \n <br />Other Well \o0,r-e �E <br />1"9 ` ) WELL LOG To7-111 depth___ 12�Depth of completed well 12 5}t <br />from ft to ft Fnrmannn ( Describe hs color character wize or matenal ) <br />sand <br />- tiardnan <br />ay <br />Qand <br />�. L a y <br />ri wasstall-d <br />and I arts not resDons able <br />fOr IMY -I - or *'&n0vLI:" of the <br />E -al Mr cas=t. <br />i <br />I - <br />r - <br />WELL SEAL <br />19) <br />Was surface sanitary seal provided' YeaX NO Z If Yes to depth'O_ft <br />(3) TYPE OF WORK <br />r Were strata sealed against pollunon' Yes ❑ No CkInterva��t <br />t ethod of zealot cement <br />',L <br />'tie- m ell Deepemn4 ❑ <br />rtrk started -19 Comple TTI19 <br />10) WATER LEVELS <br />}k <br />Depth of first water if know t <br />li c,mstrucnnn ❑ <br />Standen¢ level well <br />This u,ell waa d under Iurrs i ion a t report +a tnic to the berr of my <br />knottledge <br />- <br />b <br />Recondi nonm y, <br />SIC\En <br />Vas well test made Yes L No If vet bi -hnm° <br />� t r <br />t L t4 ! <br />Hs,nzontal \1, ellI)esttUc❑ <br />Depth to .cater a start of test ft At end of [est , , k <br />7 1�F�t! rstiSt <br />��ur�2s��Tyg�o��nnted) <br />_ <br />.6myr <br />Address .. <br />destruction (Describe <br />on materialsa ,d <br />City Oakda L e C a 1 if p 95361 <br />ectnc Int• made Yes © No [' 1f c es attach capv to this report <br />License No 133114 .mate of this report 11 / 2 3 / 8 0 <br />I <br />r <br />procedures to Item 12 ) <br />fry <br />{�f <br />(4) PROPOSED USE <br />v <br />1 <br />J <br />ImLannn <br />Industrial Cl <br />Test Nell ❑ <br />Stock Cl <br />Municipal ❑ <br />WELL. LOCATION SKETCH <br />Other � <br />f (3) EQUIPNIENT <br />(6) GRAVEL PACK <br />IRotary X <br />Reverse ❑ <br />Yes x No ❑ Size f?e� <br />C ible 7 <br />Air� <br />❑ <br />11 <br />Dtamctcr of boar <br />Other ❑ <br />Bucket <br />Packed frrrmto�. t <br />Iteel71 CASING INSTALLED <br />(8) PERFORRAWCu� <br />❑ <br />Plastic $( Concrete u <br />T%pe of perforation or size of screen <br />- From <br />To Dia Cage or <br />From <br />To <br />Slot <br />ft <br />ft in Wall <br />ft <br />ft. <br />s.ze <br />0 <br />1251 1" 1A <br />S <br />if .2 <br />Do not fill lI <br />No, 097921° <br />State Well \n <br />Other Well \o0,r-e �E <br />1"9 ` ) WELL LOG To7-111 depth___ 12�Depth of completed well 12 5}t <br />from ft to ft Fnrmannn ( Describe hs color character wize or matenal ) <br />sand <br />- tiardnan <br />ay <br />Qand <br />�. L a y <br />ri wasstall-d <br />and I arts not resDons able <br />fOr IMY -I - or *'&n0vLI:" of the <br />E -al Mr cas=t. <br />i <br />I - <br />r - <br />WELL SEAL <br />19) <br />Was surface sanitary seal provided' YeaX NO Z If Yes to depth'O_ft <br />r Were strata sealed against pollunon' Yes ❑ No CkInterva��t <br />t ethod of zealot cement <br />',L <br />rtrk started -19 Comple TTI19 <br />10) WATER LEVELS <br />WELL DRILLERS STA ME <br />Depth of first water if know t <br />Standen¢ level well <br />This u,ell waa d under Iurrs i ion a t report +a tnic to the berr of my <br />knottledge <br />after Lompletin ft <br />b <br />11) WELL TESTS <br />SIC\En <br />Vas well test made Yes L No If vet bi -hnm° <br />(Well Drtlle ) <br />Tvpe of teat Pump Bailer ❑ Air lift ❑ <br />NA.L1E Panero Well Drz1 Ln • In <br />Depth to .cater a start of test ft At end of [est , , k <br />7 1�F�t! rstiSt <br />��ur�2s��Tyg�o��nnted) <br />harge— eaI/min after timers Water temperature <br />.6myr <br />Address .. <br />cal anafvsis madea Yes No ❑ If ves by whoms <br />City Oakda L e C a 1 if p 95361 <br />ectnc Int• made Yes © No [' 1f c es attach capv to this report <br />License No 133114 .mate of this report 11 / 2 3 / 8 0 <br />t68 IREV Tel 1F ADDITIONAL SPACE IS NEEDED USE NEXT <br />CONSECUTIVELY NUMBERED FORM <br />1 10 <br />