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THE RESOURCES AGENCY <br />File with DWR DEPARTMENT OF WATER RESOURCES NO 47979 <br />\rrtce of Intent No WATER WELL DRILLERS REPORT <br />LucJ Perin it \o or Dur 5n ;iw <br />L) ONA NER \,mr i <br />�ess 12700 N. Ripon Rd. <br />c (R Rl Don <br />CA. <br />' (? ) LOC ATION OF WELL (see instructions ) <br />Count, n J TO,, ner , X, ell \umbe <br />f Wt' ll iddress if different from ibove <br />Tuumhip Rani -e Secttnn_ <br />Distance from cities roids milmids fences etc 14.� Wa sh? <br />R3.Don. <br />1 <br />at rte Nell \o <br />Other Weil \o" -' ISE-- / � t <br />r <br />(12) WELL LOG Tn1a1 depth 220 it Depth of completed -ell-2 12 It <br />from it to ft Farm-ttrnn ( Describe bs color chancier size ur matenil ) <br />0 - 21 Sand <br />21 <br />(3) TYPE OF WORD <br />' <br />25 <br />\ew Nl eil js Deepenmi, ❑ <br />Sand <br />32 <br />Reconstruction ❑ <br />Clay <br />Recnnditiumnk <br />r <br />10 <br />I 106- <br />Horizontal W ell ❑ <br />( <br />ti <br />Destructon � {Descnbe <br />Sand <br />169 <br />destruction m aerials and <br />C1a <br />2 <br />procedures to Item IZ ) <br />- Sand <br />195 <br />(4) PROPOSED USE <br />— Clay <br />Sana <br />Domestic <br />Clay <br />irnzattort ❑ <br />I ndustnal ❑ <br />' <br />Test R ell ❑ <br />Stuck ❑ <br />'+funtupol Q <br />WELL LOCATION SKETCH <br />Other Cl <br />11WQUEPMENT111) <br />GRAVEL PACK <br />Rotas Reverse ❑ <br />Yes � No ❑ S.b-i -nfi a atrA <br />C tble C Air ❑ <br />Dtarneter of bore <br />Other ❑ Bucket ❑ <br />Packed�r- <br />(r) CASING INSTALLED <br />(S) PERFORATIONS na ria CUt; <br />Steel Q Plastic Concrete C <br />Type of perromtton or stze of screen - <br />From To Dia Gage or <br />From To Slat <br />f- ft in Walt <br />ft ft Size <br />_ 0 1 212 I 160W <br />1 Qa P I P <br />at rte Nell \o <br />Other Weil \o" -' ISE-- / � t <br />r <br />(12) WELL LOG Tn1a1 depth 220 it Depth of completed -ell-2 12 It <br />from it to ft Farm-ttrnn ( Describe bs color chancier size ur matenil ) <br />0 - 21 Sand <br />21 <br />- 27 <br />C1a <br />25 <br />- 32 <br />Sand <br />32 <br />- <br />Clay <br />- <br />bana <br />10 <br />I 106- <br />- 10 <br />-108 <br />11 <br />- 9 <br />- <br />Clay <br />Sand <br />Clay <br />Sand <br />C1a <br />ti <br />Sand <br />169 <br />-182 <br />C1a <br />2 <br />-185 <br />- Sand <br />195 <br />-195 <br />-209 <br />— Clay <br />Sana <br />-220- <br />Clay <br />(9) WELL SEAL — <br />W.ts surface sanitan seal provided' Yes :rf No If ,es to dept 0' ft <br />Were strata sealed iVainst pollution" Yes ❑ No ❑ Interval FL — <br />Method of sealer Bento Work start 7 IP —19= Completed 19 <br />(16) WATER LEVELS WELL DRILLERS STATEIIE`T <br />Depth of first ,eater if known ft- This well war drilled under my Jurisdiction and this report a true to the best of m1 <br />Standinz le, el after a ell completion } . _h knowledgean belief <br />(I1) WELL TESTS SIGNED ^ /C J ) <br />Was well test made2 Yes tin Z: If ves by whom° (Well Dnller) <br />Type of test Pump Bailer ❑ Air lift 0 NAME He Ings Bros. Drilling Co., Inc. <br />Depth to s ater at start of test.—ft At end of test k_ ( rs 8rm orTorpor tion) (Typed or printed) <br />Address 3525 'eiandaf e ve . <br />I?tscharie�, ;al /mm Liter ---------hours Water temperature Od e S � � CA . zt 9 (� �0 <br />Chemical analvsrs made' Yes Q No If ves by whom" Cit> _ est P <br />■v ctrte lov made° Yes ❑ No If ,es attach cop, to this report Licerise \o _240813 Date of this report 17 ?M <br />DwR 168 (REV > neo IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM -3@16950` 76 za-ZlADQ'r osr <br />o <br />1 11 <br />