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1 <br /> (T) <br /> ORIGINAL STATE of CALIFORNIA <br /> Da nod fill a<n <br /> THE: RESOURCES AGENCY No. 079460 <br /> ����O <br /> '10 Dwith DWR DEPARTMENT OF WATER RESOURCES <br /> rl Intent No - _ W_ WATER WELL DRILLERS REPORT State Well No <br /> Permit No or "ta. Other NYelf <br /> (]) OWNER Name�+aZ7. 01 11ia Wa 1�,�re (12) WELL LOG Total de„th_ f► Depth of completed well ft <br /> Addre <br /> Post off1CB Box 11 50 from ft to <br /> ft Farmabaa (12escribe by color, character, size of metowd) <br /> (,,ty San Jose s G'A ip 1 9 <br /> (2) LCATION OJ' WELL (See[ristructions) 8 t . i 11 e d <br /> Couary a1Z JOa uzn Owner's Well r\amb Sta 41 ter consultation <br /> Well address ff different from ebov across from the and approval of L Hall, Director <br /> TawnshiD�], ool 6 het , 6th. Environmen tat Servz , San Joaquin <br /> Dlstaoco from cities roads,railroads fences,etc Local-Heal strie <br /> 1 — <br /> (3) TYPE OF WORK <br /> Now Nell Q Deepentnr 0 <br /> Reconstruction 1 — <br /> Reeaadihoning 0 <br /> klonxootal Welt ❑ _ <br /> Aostzuctton 30 (Describe <br /> rlestruchan mnt�riats <br /> procedures ip Item -- <br /> ����,L (4) 1'R0It05E1] AA <br /> Domestic <br /> 3�l� Imt;ahen — <br /> __j <br /> SUR.1- <br /> �f ¢ Industrial p <br /> (�'�' r7'��� �ve1l ❑ <br />' WELL LOCATION SKETCH (hher 0 <br /> (S) EQPIIPI%IENTt 0) GRA PACKr <br /> Rotary 0 Reverse 0 kbo <br /> No E3 Size <br /> Cable 0 Air ❑ :n of bo <br /> Other CI Bucket O t — <br />' (T) CASING INSIALLFU (8) ERF0,R t S — <br /> Steel❑ Plastic Q C cl�� Type of per n nr a of sere <br />' FroinTo Dia r F To <br /> ft. <br /> m WaII ft yr' <br /> (8) WELL SEAL <br /> Was surface samtmy seal provided? Yes p No Q If yea, to depth ft <br /> Wore strata sealed against pollution? Yes❑ No El Ince t. — <br /> Method of sea Work starte Lille I9 rom7pfeteel B 19 <br /> (1(]) WAFER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first ivaler, if Irnows4 --- �ft This reell teas drWed tinder my l+rrisdictfon and this report Is tree to the best o/ rap <br /> Standing level after well completfo t:` tnowledge ao4 belie/ <br />' (1I) WELL TESTSt StcNrn <br /> Was well test made? Yes R No 0 If yes, by whom? (Well Driller) <br /> Type of teat Pomp 13 Baner a Air bft❑ r NANI-F -Clark_ Well &-Eguipment Co. t _Inc. <br /> Depth to watet At start of test, f# At ea o€ test s_ ,_mit (Person.firm,or corporatton) (Typed or prJnted) <br /> after _ hours Water temperate Address 2-024 r Way <br /> a1 apnlyais made? Yes El No 0 If yes, by whom? Cie Sjjoaktgn a Ca TIP-9�r2Q�--- <br /> Was electric log mule? Yes 0 No 0 if yes,attach copy to this report Lrcensc No_,_,3 6a �_L�nte of this reDarl.,�. Ju1Y_.8�R <br /> WR lee trtzv v yc) IF ADDITIONAL_SPACE IS NI;I;D1;D USE NEXT CONSECUTIVELY NUMBERED FORM <br /> 1 <br />