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IV F STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY DO not fill in <br /> ,.per's Copy APARTMENT OF WATER RESOURCES `r <br /> WATER WELL DRILLERS REPORT N0. 252878 <br /> Notice of Intent No. State Well No" <br /> Local Permit Nu" or Date �7�� i Other Well No. <br /> (1) OWNER: Name 91117 Gorcery JSte I I A Ril (12) WELL LOC: Total depth 185 It. Completed depth 85 ft. <br /> Address A491 IP jAxii.�z Ferry from ft. to ft. Formation (Describe by color,character,size or material) <br /> cit, !racy . ra zip 99376 _ Tnp c <br /> (2) LOCATION OF WELL (See instructions): <br /> Uuntc_ cn,n 43oaqllin Owners Well Number 14 - <br /> 47 Clay <br /> Weli address if different from above 47 - 55 Sand <br /> Township Range Section 4 Clay <br /> Distance from cities,roads, railroads,fences,etc. Irnrnpr1 Gravel <br /> 16 1 _ 18,5 Grayri. <br /> (3) TYPE OF WORK: T �` <br /> \ <br /> New Well R1 Deepening ❑ V <br /> _ / <br /> Reconstruction ❑ <br /> Reconditioning ❑ / <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures <br /> ro cedures in Item 12) <br /> (4) PROPOSED UWP' . _ <br /> Domestic - <br /> Irrigation <br /> Industrial ❑ _ <br /> Test Well ❑ _ - <br /> Municipal'\ ❑ _ <br /> Other ❑ _ <br /> WELL LOCATION SKETCH t1Jea+vtbe) � _ <br /> (.il EQUIPMFNT: t(i) CRAVELPACK: S�aindf T <br /> Rolan �] Reverse [l i- Yea tiri`[] Size - <br /> F <br /> Cabh• ❑ Air ❑ Oiametc r of I ore t <br /> Uthrr ❑ <br /> ed from <br /> Bucket—❑ P`a� �to ��4.. � �; <br /> CASING INSTALLED. fiV PFRIt)RAT1OtiS — <br /> Str•rl ❑ <br /> Plastic [ilncwSr ❑ -rN pe of perforatlmt(ITSM'of A-reert — <br /> Front T<I� Dia. G. eor From; TO -Sb t Out I ,1 <br /> 1989 <br /> ft ft. in. %ball ft ft. sizc - <br /> rG re e <br /> PIReP it 1P <br /> - <br /> i - <br /> F <br /> (9) WELL SEAL' — <br /> \\as surEaer sanitare seal provided' les Lam., '1"n [ If ars,In dept 1, — <br /> \Crrrstr�la sa•aled a�ainsl{><illuUun? les ❑ N,r r` Interval o ft — <br /> \trlhrxi of sealing %Vo4 stork-dr- if, _Iq �.-' Gtlnplt•le•d 19_ <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known fl. <br /> Thi., av!f u•as drilG•rl rrndr•r my juriadirfion and thi, report is tote to fhr <br /> itandinp Icvel after well completion - 2G ft !rest of nig hnov'lydg(•and lx,hcf. j <br /> (111 WELL TESTS: Signed <br /> Vdassceh test made? Yes ❑ No []y ]f tes,by whom? t\\ell Driller) <br /> Tape of Inst Pump © /n\ liuiler ❑ Air lift NAME <br /> Ek•pth to water at start of test it, Al end of test ft �t'�erson. irn1.eer rnrporatrun ygrd nr pnrHt I <br /> Drx•har yr .Add,,.,,,,,,_ 2.r4�—P{I Lf Ill n n I G �r F <br /> {. �alj min after hours \1•aler lrm{rrraluh• <br /> (alrn114':Il 3nal)'sis Illadl•� <br /> )VS ❑ No II ye•s.by.e hCity r <br /> ntn? , CA Z1P-T•T�TO <br /> \\;i.rierinr h.>;made lr. ❑ Mr If ae•s.ntlarh rnlrs luthi�rrlrrrl l'icenw\n0 0Ilalenl Ihi>rrl>,�1'I �C <br /> DwR 186 (REV. 12_861 IF A DITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />