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2 <br /> ORIGINAL STATE OF CALIFORNIA Do not fIK in <br /> lie with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 21616 2 <br /> Intent No WATER WELL DRILLERS REPORT <br /> State Well N. <br /> rooWNER <br /> mit No or DatewOther Well No jName MKter (12) WELL LOG ' 7 <br /> Toni] deptl�qLft Depth of completed well 9 5 _ft <br /> 1Addre from ft to ft Formation (Describe by color charneter size or material) <br /> it A Zip 95201 <br /> 2) LOCATION OF WELL (see instructions) Clay- <br /> County S Owners Well Number 0 <br /> ll address if different from above S Stockton & Church 40 -50 Blue r e e n' C 1 d <br /> iwnship__ _ I 1 N Range—& E <br />'e -section--- 50-60 B l u e r e e n ge.rl%e Clay <br /> Distance from cities roads railruads fences etc 60 -82 61 a e,-`urreen C 1 a $ n <br /> r <br /> (3) TYPE OF WORK - <br />' New Well ® Deepening ❑ (,=�\ <br /> Reconstruction ❑ _ \� <br /> Reconditioning ❑ r`ti - V v� <br />' Horizontal Well ❑ <br /> Destruenon ❑ (DescribeF- <br /> destruchon materials ands ` <br /> procedures in Item 1_.y <br />' (4) PROPOSED USED <br /> Domestic �� ❑ ` =� <br /> Irrigation r ❑See Map At �tched Industrial <br /> Te4st <br /> Y� <br /> y - <br /> 10 Well ❑ <br /> S tock " a _ <br /> Municipal ❑ _ <br /> WELL LOCATION SKETCH J Other M W <br /> EQUIPMENT (8) GRAVEL. BACK \ _ <br /> Enta r� <br /> Reverse ❑ Yes [$ \u [] Size j 3 $'a n d <br /> IL <br /> ❑ Diame`er of bore 10— 5 8 <br /> C] _ <br /> r ® Bucket Pack.S from _ <br /> 69,.._�to 4 7 ft. <br /> 7i CASING INSTALLED (8) PERFORATIONS _ <br /> el © Plastic ® Concrete [I Type of perforation or size of screen <br /> rom FTo Dta Gage or From To }Slot - <br /> Et ft m Wall ft ? >> ft 1 \'s"ze _ <br /> C 0 95 '4ch40 80 9 - <br /> 3 f WELL SEAL _ <br /> surface sanitary sea] provided Yes ® *[o Q If yes to depth 9 # _ <br /> strata sealed against polhihn�oYes ❑ No E3Interval k <br /> k <br /> od of seahn C e m e n t & Bentoni te Work start - I u19 Complex 19 <br />[0) WATER LEVELS WELL DRIL ER'S STATEMENT <br /> th of first water if Brio This wma <br /> ll y rrrd-tion and thus report is true to the beat of my <br /> long level after well completo knornlell) WELL TESTS SIC\Eas well test made' Yes ❑ ho IN If yes by whom? (Well Dr ler) <br /> of test Pump q Bailer ❑ Air lift ❑ N�Mr 0 r 1 1 i 1 n I n c <br /> th to water at start of test—_- ft At end of test Fr (Person firm, or corporation) (Typed or printed) <br /> allmrn after. h^urs Water tempemt— Address <br /> E . made? Y. n No Qg If yes by whom' City. Palo L d r A <br /> A 1�p. 96073 <br /> electric log made? Yes F1 "(0 '� If yes attach copy to this report Lieease No 512406 - <br /> 1 2 4 0 6ate of this report 4- 13-8 9_ <br /> 188 (REV 7 Bei IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />