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ORIGINAL, STATE OF CALIFORNIA <br /> File with DWR THE RESOURCES AGENCY Da not fill in <br /> DEPARTMENT OF WATER RESOURCES No. 206208 <br /> \r ,f Intent i\n245,951 WATER WELL DRILLERS REPORT <br /> _rmit No or]]rte State Wel] \n <br /> Other Well \c 7Q <br /> 1 OWNED %ame <br /> 230 InduStrlal Avenue (12} WELL LOG Total de th <br /> Address p 1 14ft Depth of completed well 112 ft <br /> City R' On CA from ft to ft Formation in--i— by mlor ch tmeter size or material) <br /> Zip 95366 - <br /> (2) LOCATION OF WELL (see' instructions)Cotinty M-10A <br /> owners Well Number See Attached <br /> Well address if different from above <br /> Township _ <br /> Range Sectio <br /> ' Distance from cities roads railroads fences etc _ <br /> ' (3) TYPE OF WORK <br /> New Well [g Deepening ❑ _ <br /> See Attached Map Reconstruction ❑ _ <br /> Reconditioning ❑ - <br /> Horizontal Well ❑ <br /> ' Destruction [] (Describe = <br /> destruction materials and <br /> procedures in Item 12) <br /> (4) PROPOSED USE _ <br /> Domestic ❑ _ <br /> ' Irrigation ❑ - <br /> Industnal ❑ - <br /> Test Well ❑ - <br /> Stock ❑ - <br /> MunicipaI ❑ _ <br /> WELL LOCATION SKETCH Other Mpnitoring [f <br /> ' (s) EQUIPMENT (6) GRAVEL PACK _y <br /> Rotary ❑ Reverse ❑ Yes [4 No ❑ Size #3 W <br /> Cable [] Air ( Diameter of bore 9 Inch <br /> Other 0 Bucket ❑ Packed from $7 ` <br /> tri_ 114 ct _ <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> Steel ❑ Plastic Concrete ❑ Type of perforation or size of screen _ <br /> From To Dia Gage or From To Slot <br />' ft ft in Wall ft ft _ <br /> sate <br /> 92 4 Sch 4 92 112 <br />'(9) WELL SEAL <br /> Was surface sanitary seal provided? Yes OX No Q II yes to depth---15---ft <br /> Were strata sealed against pollution? Yes <br /> No ❑ Interva 1t <br /> Method of sea <br /> (10) WATER LEVELS Work start19 Complet <br /> 19 <br /> Depth of first water, if know izWELL DRILLER'S STATEMENT <br /> Standing level after well compledo _ft This well was drilled under m <br /> ft know !� inresdretian and this report is true to the best of my <br /> (I1) WELL TESTS ledge and belief Was well test made SIGNED <br /> P <br /> Type of test Yes ❑ No [ If yes by whom? (Well Drill-9 <br /> -�omp ❑ Bailer ❑ Air lift ❑ LAYNE—WE <br /> Depth to water at start of test—_ fr At end of NAME A=RN CO- ,. INC. <br /> test.�� `P fi <br /> D ge 16 0 197T a f e' On (Typed or panted) <br /> ^al/rain alter hauls Water temperature Address <br /> Ci :1 analysis made? Yes IN No 0 If yes by whom? Cano City Fontana CA Zip 92335 <br /> electric log made5 Yes ❑ No [N If Nes attach copy to•'ris report <br /> License No ate of this report—_ 9/918 <br /> 1rWR 188 (REV 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 5 <br />