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1 <br /> 3 <br /> ORiGINA� L� STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> F with DWR DEPARTMENT OF WATER RESOURCES No, 216086 <br /> f Intent No WATER WELL DRILLERS REPORT State Well No <br /> ermrt No or Bate 12-4-87 Other Well No e-IMM04F;60L <br /> (1) OWNER Nam /y e ppm C!t /j­(TfT_ (12) WELL LOG Tot a deptik A tt Depth of completed well R Il rt <br /> IAddress_ 2200 P o W l l ST from ft to ft Formation (Describe by color character size or matenal) <br /> ca-, Emeryville CA zip94608_ 0 -10 Fine sari <br /> (2) LOCATION OF WELL (See instructions) ] 0 -37 B r o to n clay <br />'C,)unty_S a n ]a a q u 1 n_ Owner s W ell Number 0 S 4 B 37 -58 Sand & Blues clay <br /> Nell address of different from above o f f S o n o r a S t , Stockton 5 8 -64 Sand <br /> T-wnship Ran„e scct:n 64 -84 S and & Blue clay <br /> a <br /> c <br /> fistance Emm Gibes rnlds railroads fences etc = _ <br />' (3) TYPE OF WORK = <br /> New Well 6 Deepening ❑ <br /> See map attached Reconstriu trop © _ <br /> Reconditioning ❑ <br /> Honzontal Well ❑ <br /> Destruction ❑ (Describe - <br /> deStRiCbOn materials ands <br />' procedures in Item 12Y <br /> (4) PROPOSED USE <br /> • <br /> Domestic ❑ — <br /> Irsigation ❑ _ <br /> Industrial ❑ <br /> Test•Well • ❑ _ <br /> Stock Q <br /> Municipal <br /> WELL LOCATION SKETCH Dth9Yf o n 1 L o r 1 n :r� — -- <br /> i 5) EQUIPMENT (B) GRAVEL PACK - — <br /> Rotaev ❑ Revene © Yes No Size I Z 2 0 4. <br /> able ❑ Air ❑ Diameter of bore 0 tt - -- <br /> Other CDBucket C:] Packed from 5 g Yo�B c 7 CASING INSTALLED (8) PERFORATIONS -- <br /> 'teegQ: Plastic ❑ Concrete ❑ Type of perfamimn or sue of screen — <br /> From To Dia Gage or From _' To Slot - <br /> ft ft. to WaU ft - ft. s-ze - <br /> 0 80 4 9 50 6 S so 1t - <br /> 9) WELL, SEAL = <br /> as surface sanitary seal provided' Yes 4P, No ❑ If yes to depth 59 ft <br /> Were strata sealed against pollution? Yes ❑ No C Interval —ft — <br /> %feth„d of seahiid Concrete /bentonite work startedII Z — 9 Completed-1- <br /> 10) <br /> nmpler 10) W kTER LEVELS ^�j � WELL DRILLERS ST kTEMEN'T <br /> epth of first water, if known weft Baas under mp ru—n a9ld report is true to the best of my <br /> Standing level after well completso I 'kyoNIedga and <br /> 1 11) WELL TESTS <br /> as well test made° Yea ❑ Vn-❑C If yes by w 3 11 We11 D <br /> ype of test Pump ❑ Bader ❑ 1 _l TAIV,hf3 ❑ A 1 D 1 am a n d Co e D r 1 Z n I n t <br /> to water at start of test ft fA�nd of���[ (Person, firm or corporation) (Typed or pnafed) <br /> i LZ <br /> 10556 _Pet.unaLane <br /> e R%I/aei>1 after hour; 1nv,Q er temper Addressr — <br /> 1"�l c '®Palo Cedro CA QfiOZ3_ <br /> analyses made' Xis [; '+Io=flC If yes by dyhyol? ,•••� r' 4A.—.0 5 124 0� 12—4- <br /> c lag made Yea ❑ No;� If yes attashic J fn report No ata of this report <br /> t <br /> DWR 188 II49V > 76) IF ADDITIONAL. SPACE 1 Ikfiitl'41SE ( OoNsECUTIVELY NUMBERED FORM <br /> 1 I _Y~ <br />