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ORIGINAL STATE OF CALIFORNIA Do not fill to <br /> THE RESOURCES AGENCY <br /> File with DWS DEPARTMENT OF WATER RESOURCES No. 128676 <br /> ' of Intent NopW � <br /> WATER WELL DRILLERS REPORT <br /> Permit No or A1tc_ (V 74 State WellNa _ <br /> L I Id �L _ t <br /> Other Well No'll <br /> OWNER V3me Pedro rDe a d Allo (I2) WELL LOG Total de th 1 40 <br /> Address 21-71S . .1.I'c�Cy �1Vd• p It Depth of completed welt 1 4 0t <br /> from ft to ft Fnrm ikon (Describe by color char-icter sire or material) <br /> city, a . Zip 0 - To soil <br /> (2) LOCATION OF WELL (See instructions) - QQ C a & shale <br /> County a 27 eJ{7 uyn Owrier s Well Number (� 2b Sand <br /> Well address if different from 'ibove 2r8 — /2� Clay <br /> Township —Range—section <br /> ange ecbn <br /> S -z2 — Q Sand <br /> 27 <br /> Distance from Cities roads railroads, fences etc Tra y Bly d Q <br /> 400, North of Larch Ru . rest sa de 70 - 3 San <br /> - ay/ 0-LUe s reales <br /> .118 Sand-fine <br /> (3) TYPE OF WORK 1New Well X Deepening ❑ 140 lay <br /> Reconstmetoon ❑ _ <br /> Reconditioning ❑ <br /> Horizontal Well ❑ ''1 _ •-�• <br /> Destruction ❑ (Describe _ <br /> destruction materials and <br /> Procedures in Item 12) — _ -- <br /> (4) PROPOSED USE - <br /> Domestic x) _ J <br /> Irrigation ❑ _ — <br /> Industrial ❑ _ v <br /> Test Well ❑ _ \ <br /> Stock ©- <br /> Municipal 0 <br /> WELL LOCATION SKETCH Other ❑ <br /> (5) EQUIPMENT (6) GRAVEL PACK 1.. _ ti <br /> Rotary [Z Reverse C) Yes El No ❑ Size lJ�..r d s e e <br /> Cable [] Air1 #11 <br /> ❑ Diameter of bore .. <br /> Other ❑ Bucket ❑ Packed fromQ �tu <br /> (7) CASING INSTALLED (8) PERFORATIONS <br /> Steel ❑ Plastic B Concrete ❑ Type of <br /> perforation or sae of screen _ <br /> From To - Dia Gage or From TO Slot - <br /> ft ft to Wall ft ft '%S.ze _ <br /> screen - <br /> (9) WELL SEAL _ <br /> Was surface sanitary seal provided;' Yes:M No ❑ If as to depthl)Lft — <br /> Were strata sealed against pollutivnO Yes <br /> ❑ No ❑ Interva��g — <br /> Method of sealer Be tonite <br /> Work started Completed-1c) <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water if knouri $ This well was drilled under m <br /> Standing level after well completion ft knowledge and beh i! jurisdiction and this report rs here to the best of mid <br /> (11) WELL TESTS Sll <br /> Was well test madea Yes ❑ No If yea by whom (Well Driller) <br /> Type of test Pump ❑ Bailer ❑ Air lift ❑ NAME Hennin S Br S • Drilling CO• inc o <br /> Depth to water it start of test _ft At end of test_ ft (Person, firm ora atwnl (T)ppt or Vn3geoI , <br /> P `1rge�gal/nun after hours Water temperatureAddress �152 a ria a I e is e <br /> al anabsts madeP Yes ❑ No:6 If >es by whom" city Modesto� Ca . ^-7 <br /> s electric log made Yes [] Nopp LL ^pp <br /> If Nes attach copy to this repp License Nv9 QU `"nAte of this report V C: <br /> R 168 (REV > 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBtRE6 F+OFtM~ <br />