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STATE OR CALIFORNIA _ Do Not Fill+in k <br /> F. THE RESOEJF2CES,-AGENCY----.-,- <br /> File <br /> 3 PiGENCY <br /> ORIGINAL DEPARTMENT OF WATER RESOURCES N� 6 3 O o+ <br /> File with DWR '€: 0 1,.. <br /> r WATER WEiLL DRILLERS REPORT s=are Well No <br /> r r� <br /> ✓_ Other Well No <br /> (1) OWNER: <br /> (i 1) WELL LOG: <br /> Dame T_d Tin kna-.... <br /> �: Tatil depth ft. Depth of completed.ell ',•`Er. <br /> Address040 Loom q PA _ <br /> Formation: Drsniir by rotor,eberacler,si,of mntrrial,and stractnrr <br /> f[,to <br /> (2) LOCATION OF WELL: <br /> t.uuntY San J a <br /> oa n�.n Uaner's number,if any� ..�` Township,Range,and Section <br /> } �QLLn_ltamliz_ad Sand <br /> w. On <br /> Disunce from 6its,roads.railroads,etc. <br /> (3) Cl ay <br /> TYPE OF WORK (check): <br /> and <br /> + New Well M Deepening ❑ Reconditioning .. <br /> ❑ Destroying ❑ <br /> 11 destruction;describe material and procedure in Item 1I. _ <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> DomesticIndustrial <br /> ® E] Municipal ❑ RotaryEia 86..88 Ire <br /> Irrigation ❑ Test Well ❑ Other ❑ <br /> Cable 13 <br /> Other ❑ <br /> (b) CASING INSTALLED: clay <br /> h-1 15 <br /> STEELx OTHER: If gravel packed <br /> SINGLE ® - (DOUBLE ❑ Clay <br /> Sand <br /> Gage DiameterCjay <br /> From [b or of Fromo <br /> f=. ft. Diam.- Walt Bore f=. TT <br /> I <br /> S-of,hoe ir well ring: <br /> Sire of anvel: e - <br /> oestrihe juror welded . <br /> (7) PERFORATIONS OR SCREEN: <br /> f Ype of oeriu-dun or name pt s[reen _ <br /> it <br /> Perf. Rows <br /> From To per per Size <br /> ft. f=. <br /> -- f= row in.x in. <br /> 74 <br /> tf <br /> .r <br /> f <br /> ' I <br /> (8) CONSTRUCTION: SR;, <br /> Wa,a,urtica;anicuv heal provided? Yes No ❑ To what deprh fr. <br /> _ Were anti,trs:a..aIed sgainsr pallvt;on? yea❑ No n ' <br /> u If yes,mute deprh aE strata <br /> From f[,to it, <br /> Fmrn ft.m ft. tNAm <br /> k st,rted 72 �J 7 <br /> 19 Campieted 9-2!. 19 <br />[ <br /> Method�f,e�Gng LL DRILLER'S STATEMENT: <br /> (9) WATER LEVELS: bis well was drilled under my jurisdiction and thio report is true to the best <br /> Depth at which water was first foursd, if'Fnawa y knowledgeand belirif <br /> f t. <br /> handing'level before perforsting, ;f known :FEHennings Bros. Well DrillingC Inc <br /> standing leve! after `O S <br /> perforating and developing Cyt. (Person,firm,orcorporationk (Typed or printed) 4 <br /> 00) WELL TESTS: Address 2500{W. Rumble Rd. <br /> Wax numv rr made? Yea E] No If yes,by whom? Mode S • <br /> 4O Calif O. <br /> s <br /> g,i•rmin.witF, ft.drawdown after hes. (SIGNED] <br /> Ternpenrnrr of-r" �Tas a chemical analysis made? Yes ❑ tiu _ i'Wrlt Dr+f <br /> Was elerrric log mad'of well? Yes ❑ N If yes,attach copy 622 <br /> License No. 'Dace I9---7-2 <br /> SKETCH LOCATIO14 OF WELL ON REVERSE SIDE <br /> DWR tee rREV, 9-681 ' t <br /> VLL 2$170-930 9-e8 COX TRI r An OSP` <br /> E <br />