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ORIGINAL STATE OF CAI-IFORNIA Do not fill in <br /> THE RESOURCES AGENCY ile p�with DWR DEPARTMENT OF WA+ER RESOURCES NO. 128643 <br /> nF Intent Nor+^�� WATER WELL DRILLERS REPORT State We]]No <br /> 1'erinrt No or Date "2001Other Well No <br /> 11) OWNER r�ri1e_ - , HUNTER TRAV t (12) WELL LOG 'Total depth?5 ft Depth of cornpleted WelL_ • t <br /> SERVICE �+ '- <br /> Address ��xx 9 W• Center St• Suite e from ft to ft Fonnahon (Describe by color character size Or material) <br /> itv_11 — <br /> Zip <br /> 12) LOCATION OF WELL (See tnstruehons) 18 Blue ('1AY <br /> County_S fl n Owners Well Number <br /> 11 address if drffer"t from above 16 _ 0 Sand \ *. <br /> ,wriship Range —Section 66 Clay <br /> te <br /> ,� <br /> Dmance from cities roads railroads fences, etc 66 68 Gravel <br /> S t CORNEP OF HWY 120 & AIRPORT WAY 68 80 C a� <br /> Sand <br /> 1ny <br /> (3) TYPE OF WORK <br /> Ne,c Nell <br /> Deepening ❑ 1 —* 125 Clay <br /> Reconstruction ❑ 135 Ea. L <br /> — <br /> Recundlt,onmg ❑ <br /> Cl <br /> Hon7ontal 41 ell ❑ -137-- 140 S anal <br /> Destniction ❑ (Describe 140 — 145 Clay <br /> destmeturn materials and <br /> procedures to Item 12) — <br /> h <br /> (4) PROPOSED USE - <br /> Domesh( 7 - <br /> Irrigation ❑ — <br /> Industri J ❑ — <br /> Test W ell © _ <br /> Stock ❑ — <br /> 1 <br /> Municipal 0 WELL LOCATION SKETCH Other ❑ — <br /> 5) EQUIPMENT (6) GRAVEL PACK y — <br /> Rotar) IX Reverse [D yes EX No ❑ Srze tbie eble — <br /> ❑ Air ❑ Diameter of bore- 1211qq 11''�� <br /> ther ❑ Bucket ElPacked from. t _Jt — <br /> (7) CASING INSTALLED (8) PERFORATIONSm1w — <br /> eet ❑ PlasticM Cont'reke Q\ Type of perforation or sire of screen < �� — <br /> From To - Dia Gag~ei¢ Frolt�'` ,j To ���Slot <br /> ft ft l m Wall It ft14tk 3 60 65 <br /> 7 - <br /> (9) WELL SEAL - <br /> �a5 surface sanitary seal provided? Yes CX No CD If yes to deptb_�Q_1 ft = <br /> ere str rta sealed against pollutions Yes C) No ED Interval ft <br /> Method of sealrn Work started9 Completed .19 <br /> to <br /> ) WATER LEVELS WELL DRILLER'S STATEMENT <br /> pth of first water if known ft This well teas drilled under ml� rurrsdiction and this report rs true to the best n/ mg <br /> ndmg level after well completion 1 ft knowledge and belief <br /> I � /� f <br /> (1I J L TESTS SIGNED C , <br /> I <br /> ; gsv,�e� Yes ❑ No� If yes by ,vhom° (Well Driller)tie Pump ❑ Bailer ❑► Air lift ❑ NAME HENNINGS BROS. DRILLING 0INC. <br /> eptgter t g1fCy�fE test ft At end of test ft (Person firm or corporation) (Typed or printed) <br /> �• f Address 1525 Pelandale Amenu? <br /> *;Lanalysjynade? ours Water temperature -jcttr Mnciestn_ „California zip[ f _� If yes by Whni>37 - •^ •� <br /> rt jiily 5>4- <br /> C log rraile'? a Yes 7NO If)es attach copy to this report Luense No 29081 Date of this repo <br /> DWR 18 t 7 7e) 'IFA ITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> L �f� <br />