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ORIGINAL STATE OF CALIFORN[A Do not fill in <br /> THE RESOURCES AGENCY <br /> 227012 <br /> � r� <br /> He with DWR DEPARTMENT OF WATER RESOURCES NO. 2 2 7 0 1 2 <br /> I'I Le of Intent No WATER WELL DRILLERS REPORT State Well No <br /> Permit No or Date Other Well NoOI <br /> 1) OWNER Name "IVa C (12) WELL LOG Total depth—,]„Z5ft Depth of completed welLI-24ft <br /> res 10560 6 McKinleyfrom ft to ft Formahon (Describe by color chanti.ter size or material) <br /> grench �a1$I Zip on <br /> Soil <br /> (2) L CATION OF WELL Hiardpan <br /> g (See [natrvctioris) <br /> county an Joa^iln,n Owners Well Number <br /> cIl iddress if different from zbove 15 2p1, Clay nwnship Range Sectio 21- 28 Sand <br /> Di-tante farm cities roads railroads fences etc 2& 33 V 1$ <br /> 33- 36 -aand <br /> 1 a.y <br /> end <br /> (3) TYPE OF WORK lay <br /> New Well JC Deepening Q "Oarse San <br /> Reconstruction ❑ ay <br /> \�! Reconditioning ❑ - OarSe sand <br /> Y <br /> I-Ionzoatal Well ❑ 9fE % y <br /> nes:ruction _ arae s an <br /> destruction mi <br /> materials and - <br /> �i procedures to Item 12) <br /> �t (4) PROPOSED USE - <br /> Q Domestic Ix _ <br /> '`4 Irrigation ❑ <br /> Wr4 Industrial <br /> Q ❑ andnot- <br /> _ i responsijni-e <br /> -\ Test Well ❑ for -m t? niig of the <br /> Stock ❑ caso <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> EQUIPMENT (B) GRAVEL PACK - <br /> Rotary []{ Reverse ❑ Yes EX No Q Size - <br /> able ❑ 4rr ❑ Diameter of bore {1 <br /> other ❑ Bucket ❑ Packed from - -5ifh�to 1 ft - <br /> f') CASING INSTALLED (S) PERFORATIONS - <br /> Steel ❑ Plastic)[] Concrete ❑ Type of per-foratian or size of screen - <br /> From To Dia Gage or From To Slot - <br /> ft ft in Wall ft ft size - <br /> n 125 " Pll - <br /> r <br /> 1191 WELL SEAL - <br /> Was surface sanitary seal provided? Ye No ❑ If yes, to depth---5Q-ft <br /> Were strata sealed against pollution" Yes ❑ No TL IntervaI ft <br /> Method of Qeahn L'vork started Jlit" 19 Complet.v7 19 <br />'I 10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water, if known- -_ - -- -- ft This well was d under ire~[urns ion a <br /> Standing level after well complehor knaicif his Hort is tore to the hest of my <br /> �Ft edge a eh <br /> (11) WELL TESTS SIGNED <br /> Was well test madea Yes ❑ No7t If yes by whom {Well D er) <br /> T,lie of test Pump ❑ Bailer ❑ kir lift ❑ NAME P an er 0 A e l l jj r Z I Inc . <br /> Depth to %%ater at start of test ft At end of test # Persn jt fir i or corpnr3i}on) (Typed j r printed) <br /> Discharge nal/ruin after___ _� hours Water temperature Address 314 k �O 7n e 4-r e e Rd. <br /> ental analysis made? Yes " Ci Oak d a 1 e, a 11 i eT Zip 9.5361 <br />'— ❑ No ❑ If yes,attach <br /> whom h a — <br /> rlectrc log madea Yes ❑ No ❑ If ves, attach sopa to this report LicenseNo 333114 Date of this repo"' ��1 <br /> CWR Ia8 (REV y zee IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />