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ori qi . <br />� RIGINAL STATE OF CALIFORNIA <br /> Do not fill an <br /> THE RESOURCES AGENCY <br /> le DWR DEPARTMENT OF WATER RESOURCES No. 249203 <br /> of Intent No WATER WELL DRILLERS REPORT State well No <br /> Permit No or Date G 20 Other Well Ru Z <br /> OWNER Name John Avila (12) WELL LOG 'Total depth 17 8 ft Depth of completed welll 7L ft <br /> ldress 11061 Clover Rdo from ft to ft Formation (Descnbe by color character size or material) <br /> Tra -.v, Ca Zip 95 l - 2 Ton c <br /> 1) LOCATION OF WELL (See instructions) <br />�Unty San da CL2In—owner s Well Number 10 14 S nd <br />,11 address if different from above 20 Clay <br /> M nship Range Sectio �+ 20 - 30 Sa nd <br /> stance from cities roads railroads fences etc r' e S t o1 Tracy 3 - 42 Clay <br /> Blvd. 2 - 45 Sand <br /> 45 118., Clay <br /> 118 - 120 Fine Sand <br /> (3) TYPE OF WORK 120 - 108 cla <br /> New Nell Z Deepening ❑ -- Sand <br /> Reconstruction ❑ 173 - 17 Cla <br /> Reconditioning ❑ _ <br /> Horizontal Well ❑ _ <br /> Destruction ❑ (Descnbe - <br /> destruction matenals and <br /> procedures in Item 12) <br /> (4) PROPOSED USF, — <br /> Domestic <br /> Irn$atmn ❑ - <br /> Industrial ❑ <br /> Test Well ❑ _ <br /> Stock 0 _ <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ - <br /> I EQUIPMENT (6) GRAVEL PACK --, - <br /> tan 10 Reverse ❑ Yes It No ❑ Size Gravel _ <br /> ble1 1 !! <br /> [] Air ❑ Diameter of bore - <br /> ier [] Bucket ❑ Packed from- 5 0 to 178 ft <br /> i CASING INSTALLED (8) PERFORATIONS - <br /> el p Plastic Concrete ❑ Type of perforation or size of screen <br /> From To Dia Gage or From To Slot <br /> ft ft in Wall ft ft size <br /> 0 178 1 0 1 17 Screen - <br /> WELL SEAL — <br /> is surface sanitary seal providedP, Yes t No ❑ If yes, to depth--5LCL __ft <br /> re strata sealed against pollution? Yes ❑ No ❑ Interval ...__ft - <br /> Lhod of seahn Bentonite <br /> �i ork started_- • 19 Completed-19- <br /> 3) <br /> omplet 193) WATER LEVELS WELL DRILLERS STATEMENT <br /> pth of first water if known ft This well was drilled under my ptrtsdrehon and this report is int o the best o} mg <br /> riding level after well completion 26 ft knowledge rid belie <br /> 1) WELL TESTS �_ <br /> 7� Siri'�ED <br /> 5 well test made Yes ❑ No Y1 If yes by whom9 (Well Driller) <br /> Vt Pump ❑ sailer ❑ Air lift ❑ NAME HENNINGS E}RCS . DRILLI.NG CG. T£17C . <br /> tater at start of test ft At end of test `oft (Person firm or corporation) (Typed or printed) <br /> charge gal/min after hours Water temperature Address_ 35 25 FELANDALE AVL . <br /> cal analysis made? Yes ❑ No J-t If )es b) whom City140DEST0 s CA Nov. <br /> 953i6 �} <br /> -lectnL lost mkde' Yes No r If i es attach c to this report License No 2 0/0 81 Nov• 2 G 1983 <br /> ❑ � opY p 3 Date of this repo <br /> I/S 188 (REV 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />