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ORIGINAL STATE OF CALIFORNIA <br /> THE RESOURCES AGENCY Do not fill in <br /> le with DWR DEPARTMENT OF WATER RESOURCES No. 065056 <br /> °f Intent No, WATER WELL DRILLERS REPORT <br /> Permit No, or Date UU-671 State Well No. <br /> Other Well NoGZSQ�2r'�� <br /> }moi) OWNER: Name T E u i m e n t Rental (12) WELL LOG: <br /> Tota] dept}2_0_Q_ft. Depth of completed well ft. <br /> Address t7. ) S from ft. to ft. Formation (Describe by color, character, size or material) <br /> Zip 95376 0 - 5 To Soil <br /> �i) LOCATION OF WELL (see instructions): 5 - <br /> Counh lJ j jf _DW ner's Well ;Cumber <br /> 4 . Sand <br /> ell address if different from above 24 - 3 5 O l a <br /> &.dwnship RangeII .( t <br /> Sectio 35 _ 4 i Sand <br /> Distance from cities, roads, railroads, fences, etc t �'1 .S of 41 - 47 C i a <br /> r ' sman Rd , a _ o <br /> �... 71 - <br /> F <br /> OF WORK: - <br /> Deepening ❑ <br /> r ❑ _ <br /> ❑ _ <br /> Horizontal "'ell ❑ - -- <br /> Destruction ❑ (Describe = ` <br /> destruction materials and <br /> Procedures in Item 12) <br /> (4) PROPOSED USE: - <br /> Domestic <br /> Irrigation ❑ <br /> Industrial ❑ _ - <br /> �� Test Well ❑ _ <br /> iStock ❑' _ <br /> Municipal <br /> WELL LOCATION SKETCH Other ❑ - - <br /> Ort) EQUH'MEN•I'r (6) GRAVEL PACK: S a-n d' & _ <br /> Rotary Reverse ❑ Yes L.A No ❑ Size r _ <br /> able ❑ Air ❑ Diameter of bore 12" <br /> _ <br /> y�her ❑ Bucket P..ked_fmm 3 5 . 75 t <br /> (7) CASING INSTALLED: +- 8)•PERFORATIONS: <br /> Bei ❑ Plastic (X Concrete ❑ Type of perforation or size of screen - - <br /> `,Froin To Dia. Gagi�or From, , To Slot`- — <br /> ft. ft. in. Wall ft.` ft. size <br /> 0 75', 6. . 160 55 75 "Screen - <br /> (9) WELL SEAL: \ 'as surface sanitary seal provided? Yes (M No ❑ If yes, to depth_3_5_`ft. <br /> }mere strata sealed against pollution? Yes ❑ No ❑ Interval. ft - <br /> Method of sealing—_—B e n t o n i t e Work started _E:19= Completed i9 <br /> '14) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> epth of first water, if know ft This well was drilled under my jurisdiction and this report is true to the best of my <br /> Landing level after well completion- _ rS `ft. knowledge and beef <br /> (lI) SIG\ED <br /> WELL TESTS: <br /> 1 u _ <br /> 'as well test made? Yes ❑ No [X If yes, by whom? (Well Driller) �- <br /> 'pe of test Pump +] Bailer ❑ Air lift ❑ NAME. . _HEWN_I_N G S B R O S. D R T I I T N Gf'n I N C <br /> epth to water at start of test—ft. At end of test ft (Person, firm, or corporation) (Typed or printed) <br /> ft <br /> trge_ nal/min aer hours Water temperature Address 3525 P E L A tl Q A I F A A F _ <br /> ` � MEODESTO , CA <br /> �iral analysis made. Yes 0 No IN If yes, by whom? ;ty <br /> 'as electric log made? Yes ❑ No M If yes, attach copy to this report License No 2 9 0 8 1 3 nate of this repo 7 <br /> Lr <br /> DWR 188 (REV.7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i.r <br />