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ORIGINAL STATE OF CALIFORNIA <br /> File with DWa THE RESOURCES AGENCY DO 170E fill !1! <br /> of-Intent <br /> DEPARTMENT OF WATER RESOURCES NO. 086088 <br /> e `„ WATER WELL DRILLERS REPORT <br /> Pernit �\o or Dtte Stite Well \o <br /> Other Well No +- <br /> OWNER .,,t meddle �Q�aaeteno <br /> Address p (I2) WELL LOG Toll) de th140 � y��2365 s • IIIa �i Ve p ft Depth of completed ttell�. LL._ft <br /> th' i-Qon Ca from ft to ft Form-Ihom (Describe by color ch-Ir-Icter ave or m-Iterml) <br /> (tic • 0 - <br /> Zip To so11 <br /> ' (2) LOCATION OF WELL1 <br /> C,unts (sec institutions) Hard an <br /> Ossners %[ep Number - 2 CZaV `�" <br /> %%ell address if diflerent from ibove 2 _ O L sha e <br /> Toss nsh�p Sand <br /> R-Inde Sector S a�E' <br /> Distance from cities raids r-Iulroids fence~ etc S . ��ilrna Ave.., <br /> 1m�Ie side an <br /> - 62 Shale <br /> ' 62 <br /> (3) TYPE OF WORK S - <br /> \est A[ell Z Decpenim. ❑ _ i <br /> t Recumstnuttnn ❑ (" _ 1 2 S I'1 <br /> Reconditioning1111 <br /> 112 - llb Shale <br /> Horizontal NN ell ❑ 1 '� _ ' <br /> escribe t Cla <br /> destruct on mion ❑aterialsc 'Iyid i - 1 1 Sand <br /> prMcclures in Item 12) 1 39 - 1 O Cla <br /> (4) PROPOSED USE _ L <br /> Domestic _ <br /> ]rrlgition Q _ <br /> Industri t] ❑ - <br /> Test Well _ <br /> Stock ❑ _ <br /> Municipal 0 _ <br /> LS ELL LOCATION SKETCH Other ❑ _ <br /> (5) EQUIPME\T (B) GRAVEL PACK <br /> 'Rotary x Res ersc - <br /> ❑ Yes_q No ❑ Sue <br /> CIble C Air ❑ Diameter of boreT1 <br /> Othtr [] Bucket Ll Packed frnm-. � <br /> Q hr—1 L�-S.L—ft <br /> II') <br /> CASI\G INSTALLED (8) PERF'ORATIO%S v _ <br /> teel ❑ Pl-Istle Concrete ❑ Tc <br /> pe of Perforation or size of screen _ <br /> From To Dia Gage or From To SIot <br /> ft ft in W III ft ft <br /> s.ze <br /> 0 4 - <br /> 9) WELL SEAL <br /> %'as %tirf ice %tnitan sea] Provided" les <br /> -V An ❑ If ses to depth_5jQ_ft _ <br /> Ntem strata sealed tt;amst pollutions Yes © \n ❑ Intenah��t <br /> fethod of seabn Bentnnite <br /> 10) WATER LEVELS Work started — I9 C] Comp]et lg <br /> Depth of first water if know «ELL DRILLERS STATEMENT <br /> Standin, level after %seI] cornpietft This Moll uas drilled under my mrisdictron and thi epurt is trite to the ft <br /> WELL TESTS est of lily <br /> xtn 2{� knoutledRe an belt <br /> 11) i <br /> I-Is well test ni idaaS!G\ED <br /> spe of test Yes ❑ \oX 1f ses bs schont° (Well Drl er) <br /> Pump ❑ H-Ii]er ❑ Air lift ❑ T- <br /> Depth to w-Iter at start if test ft At end of test T <br /> ft NAME (Person firm or corporation) (Typed (or printed) <br />�ischarge__gal/min -Ifter Address_.,_52� e 1.a n d a l e <br /> �.�hours W-Iter temperature �Vf3 ii � <br /> --I1 -inahsis rn-Ides Yes ❑ \og If yes by tshoma City Modesto <br /> y electric Ing m-Idel )es gg q <br /> CI \n If ses -Itttch copy to this report License 4o_ _ ?90V 1 <br /> —Date of this repoE!� 7Q <br /> lea (REV 7 76 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 8 <br />