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,I Intent <br />Pennit No. or Date r . % —1 S7 <br />STATE OF CAL'I FORN IA <br />THE RESOURCES AGENCY <br />DEPARTMENT OF WATER RESOURCES <br />WATER WELL DRILLERS REPORT <br />Do not fill in <br />No. 168966 <br />State Well N, <br />Other Well N <br />(1) OWNER: Name t" <br />Address 6352 4. Cmied 13rim <br />(12) WELL LOG: Total depth-,2-1-7—ft. Depth of c„mpleted well ft, <br />from ft. to ft. Formation (Describe by color, character, size or material) <br />City `1'.Caf.`.y) C_-ilil. • 95376 Zits <br />(2) LOCATION OF WELL ( See instructions) : <br />County S Ji t2 - i.min O)vner's Well Nurrlber <br />Well addrrOFs diff iniTom9alove.2..7 .i��flj Orta. zlo T'Vief <br />r - <br />soil,a <br />_GraNhal, <br />' <br />t — 24 <br />Gravel & clay streak -3 <br />Township 'i7Y'.-if` 1 Range Sectio <br />24 <br />Kiri: <br />Cx1 lav i <br />Distance from cities, roads, railroads, fences, etc. <br />tri — <br />95 <br />5; llrl cl-V <br />95 - 97 <br />Gzava1 <br />104 <br />L - <br />107 <br />(; avel <br />;T <br />l <br />(3) TYPE OF WORK: <br />New Well:] Deepening <br />Reconstruction <br />Reconditioning <br />Horizontal Well <br />Destruction ❑ (Describe <br />destruction materials and <br />procedures in Item 12) <br />(4) PROPOSED USE: <br />Domestic <br />Irrigation <br />Industrial <br />Test Well <br />Stock <br />Municipal <br />Other <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />❑ <br />a <br />❑ <br />❑ <br />❑ <br />❑ <br />107 - <br />115 <br />nx 2 aix <br />113 - 123 <br />d3rarval <br />123 — - 1.36 <br />Brown -.clay <br />130 — 145'Vl'�wm-1 <br />145 — 15 6) <br />Grawbi ?t clay ;strIat- <br />Y t5 - — 217 <br />13my, s'i Flay <br />— <br />- <br />— <br />— <br />— <br />— <br />— <br />WELL LOCATION SKETCH <br />— <br />(5) EQUIPMENT: <br />Rotary =Cx Reverse ❑ <br />Cable ❑ Air ❑ <br />Other ❑ Bucket ❑ <br />(6) GRAVEL PACK: <br />Yes ( No ❑ Size <br />Diameter of bore 12" <br />Packed from 1 U�— <br />— <br />— <br />— <br />(7) CASING INSTALLED: <br />Steel ❑ Plastic x) Concrete ❑ <br />(8) PERFORATIONS: <br />Type of perforation or size of screen . <br />— <br />— <br />From To Dia. Gage or <br />ft. ft. in. Wall <br />From To Slot <br />ft. ft. size <br />- <br />- <br />I16 J 6 160 <br />130 1 Cl <br />- <br />(9) WELL SEAL: <br />Was surface sanitary seal provided? Yes:IN No ❑ If yes, to depth 100 ft. <br />Were strata sealed against pollution? Yes No ❑ Interval ft. <br />Method of sealing—; <br />- <br />— <br />Work started <br />19 Completed " r' "i t 19 <br />(10) WATER LEVELS: <br />Depth of first water, if known <br />Standing level after well completio* <br />ft• <br />ft. <br />WELL DRILLER'S <br />This well was <br />knowledge and <br />SIGNED <br />STATEMENT: <br />drilled under <br />belief. <br />my iurisdiction and this report is true to the best of my <br />(11) WELL TESTS: <br />Was well test made? Yes ❑ No ❑ If yes, by whom?t <br />Type of test Pump Cl Bailer ❑ Air lift E] <br />Depth to water at start of test ft. At end of test <br />Discharge-----gal/min after hours Water temperature <br />Chemical analysis made? Yes ❑ No ❑ If yes, by whom? <br />Was electric log made? Yes ❑ No ❑ If yes, attach copy to this report <br />ft <br />NAME <br />(Well Driller) <br />v tox iyil .t'yj Co•" 1x". <br />( Person, firm or corporation) ( Typed or printed) <br />Address 300 S. 11iliolly, <br />City-1wL10C ii31_if, zip �35)3c3J <br />License No. �`1 3J� Date of this report 2-10-3t3 <br />DWR 188 (REV. 7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />