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IGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> th SWR DEPARTMENT OF WATER RESOURCES NO. 076002 <br /> of Intent No WATER WELL DRILLERS REPORT Sttte Vv ell No <br /> i <br /> I Permit No or Date 1 -3�� Other Well No ���.� � � - �r� <br />(1) OWNER same Don Cose (12) WELL LOG Total depth-21 ft Depth of completed well!1,., , <br /> ress <br /> P.O . Box 326 from ft to it Formation (Descnbe by color, character size nr material) <br /> Tracy, Ca a Zip— O soi <br />(2) LOCATION OF WELL (See instructions) _ Clay <br /> Sa J ul wCj Oners Well Number andInt,_ <br /> aGravel <br /> i address if different from above tr <br /> Tottsnship Range. – Sectio – aJ <br /> once from cities ronds railroads fences etc Lot C New – av <br /> iKL <br /> erusalem Koster Rd .—south of 56 - 80 Clay <br /> WDurham .Ferry Rd. west side 80 - Grave <br /> C ay <br /> (3) TYPE OF WORK rave <br /> New AVell.1 Deepening ❑ 11ti Clay <br /> Reconstruction ❑ 1 – 15D Gravel- <br /> Reconditioning ❑ -150 – 152 ClAy <br /> Horizontal Well ❑ 1 162 Gravel <br /> Destruction ❑ (Describe 1 62 – 2 1 <br /> destruction materials and <br /> ' Clay <br /> procedures in Item 12 = <br /> (4) PROPOSED US9.' <br /> Domestic , [ ' <br /> r �R <br /> IIrigatlfin 4 - <br /> Industrial y � F s ❑ - - <br /> Test Well ❑ <br /> Stuck .Q` – <br /> Municipal ❑'WELL LOCATION SKETCH Other ❑ – <br /> a) EQUIPMENT (B) GRAVEL PACK Roofing - <br /> n Reverse _ <br /> ❑ Yes No ❑ Size <br />; e ❑ Air © Diameter of bore <br /> It – <br /> JJtier ❑ Bucket ❑ Packed frumtuV_�fi - <br /> -> CASINC INSTALLED r (8) PERFORATIONS – <br /> © Plastic EX CnrlGfete ❑ Type of perforation or size of screen – – <br /> rom To Dia Gage or From To Slot <br /> ft ft in Wall ft ft s.Ze'170 6 160 150 170 sere= - <br /> r <br /> WELL SEAL - <br /> 1 surf-ice s-tnitary se it provided' lies [% No 0 If yes, to depth 5._ft <br /> "ere atrita sealed against polluhuna Yes ❑ No ❑ Interval ft – <br /> Method of seahn Cement Work started-----tLm–J--5—I9= Completed liJ <br /> } NATER LEVELS WELL DRILLERS STATENIENT <br /> of first water if know ft This melt was drilled under nrit Jurisdiction and this report is true tri the bes7 of my <br /> atlndirig level after well completio+ —ft knowledge and belief <br /> WELL TESTS SIGNED J <br /> t'jneil lest mAde" Yes ❑ No JX If yes by whorn' (Well Driller) <br /> T of test Pump ❑ Bailer ❑ Air lift ❑ NAME Henn ngs Bros. Drill(la Co. rin-Q, <br /> i)epa Ater at start of test ft At end of test ft LPerson firm or corporation) (T0 yped nr printed} <br /> gal/mm after hours Water temperatureAddress 352 Pelandale Ave, <br /> veal analysis made? Yes ❑ No JX If yes by whom City- Modem t o� Cs�. Zip ��5356 <br /> ' eJectnc log mode? les ❑ No If yes attach copy to this report License No29081 –' Date of this repo <br /> DWR I8 (REV 776) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />