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f <br /> f <br /> Us(to-TOMywith STATE OF CALIFORNIA Do not fill in <br /> kval requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No. 466455 <br /> i Nude of Intent No, WATER WELL DRILLERS REPORT <br /> State Well No, <br /> C.oCalPermit No.or Data <br /> Other Well No,__- i' 3 <br /> ( I }OWNER: Nam .-- r I2) WELL LOG: �}��+ � <br /> +t� t Total deptlt„_i 15. Depth of completed well .(t, <br /> Adctnts n ��T r from ft. to ft. Formation (Describe by [or, character, size or material) <br /> city Ca f. ip 6 Topsoil <br /> Z <br /> (2) LO ATION OF WELL (See instructions): - 6 CA <br /> 001-1- n �Owneds Well Number — #` sa <br /> Well rldress if different from above {# — Q Mal <br />+ Townhip Range a Sectio q 0 - <br /> r` Distelte from cities, roads, railroads,fences,etc. t4yt '1y i; � V <br /> I �� �d i► t�TQ�1. S �. _ Y <br /> t (3) TYPE OF WORK: <br /> 3 New Well Deepening ❑ <br /> Clov <br /> Reconstruction ❑ _ <br /> Reconditioning ❑ _ <br /> Horizontal Well ❑ _ <br /> Destruction ❑ (Desert e <br /> destruction materials <br /> procedures in Item <br /> (4) PROPOSED <br /> Domestic _ <br /> Irrigation ❑ <br /> Industrial O O <br /> T Well ❑ _ <br /> Stoc _ <br /> WELL LOCATION SKETCH42 <br /> ether ❑ _ <br /> (5) EQUIPMENT.- (B) GRAV ACK: <br /> Rotary Al Reverse © No Siz <br /> Cable ❑ Air ❑ r of bore _ <br /> Other ❑ Bucket ❑ ro t — <br /> (7) CASING INSTALLED: (8) PERFORA I _ <br /> Steel ❑ Plastid, Co a Type of pe a or ze of scree _ <br /> From To Dia. Ga r F To - <br /> ft. f ( Wall ft. ft. _ <br /> .1 - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes I No ❑ If yes, to depth% —ft, _ <br /> Were strata sealed against pnlluticn? es (] No ❑ - <br /> Method of sealing— <br /> Work started Compiet Ig <br /> Dept WATER LEVELS: WELL DRILLER'S STATEMENT. <br /> Depth of first water, if know ft. This well was drilled under my jurisdiction <br /> Standing level after well completio ft knowledge and bel" !f/ /ian if report is true to the best of me <br /> (11) WELL TESTS: SIGNED l Gr {,{_. [�! �/ �rlf <br /> Was well test made? Yes C] No$ If yes, by whom? (Well Driller) /�� ' <br /> Type of test Pump ❑ Bailer ❑ Air lift❑ NAME g t�s-a+ Br0 9V Drill l ol— Inir <br /> Depth to water at start of [est ft. At end of test _ft (Person, firm, or corporation) (Typed or printed) <br /> Discharge—­--gal/min after.,,,`—hours Water temperature Address <br /> Chemical analysis made? Yes ❑ No- If � ti '� ' C' r� <br /> yes, by whom? Zip 19 544 SM <br /> Was electric Iog made? Yesi �r <br /> {] No � If yes, attach copy t� --Date of this repo r� 's d o � (.�.� Li ns � �� � � ■ <br /> SWR 1815 IRFV.7.761 IF ADDITIONAL SPACEL IS IE4§ ED, USE NEXT CONS fVELY NUMBERED FORM <br /> MAN 5 1979 <br /> SAN JOAQUIN LOCAL <br /> HEALTH DISTRICT <br />