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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No. 219001 <br /> Intent No WATER WELL DRILLERS REPORT st Ak NN ] No <br /> Na or Date <br /> 8�.-329 other 11 ell N. <br /> em�rt � CC,� <br />(1) OWNER Name Tracy Ice Development `0• 12) WELL LOG Total depth 60 ft Depth of completed stelJj_ff"}}f1 <br /> Address -24500 S McArthur from ft to ft Formation I Describe by color charactero <br /> size r material) <br />(it, Tracy,, Ca zip9 5 0 - 3 To Soil <br />!2) LOCT10y OF WELL 2 Clay <br /> (See mstnictlons) <br /> Counh_ - an_ oaauln Owners Well Number 2 - 29 Gravel <br />\i ell address d different from -ibovc 29 - Clay <br /> Tuw nship —Range Sectio 4U 10 an <br /> Distance from cities roads railroads fences etc South of 01d . HWy - 65 clay <br /> 65 78 Gravel <br /> east side 78 - 125 Clay <br /> 125 - 145 Gravel <br /> (3) TYPEOFWORK 1455 1 Fila <br /> New Well IN Deepening ❑ <br /> Reconstruction 0 <br /> Reconditioning p - <br /> Horizontal Al ell ❑ - <br /> Destruction ❑ (Describe - <br /> destruction materials and <br /> procedures in Item 12) <br /> (4) PROPOSED USE - <br /> Domestic -- <br /> Irrigation ❑ - <br /> Industnal ❑ - <br /> . Test W e11 ❑ _ <br /> Stock ❑ <br /> i <br /> Municipal 0 - <br /> %ELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT (6) GRAVEL PACK Sand & - <br /> Rotary 5 Re,erse ❑ Yes TD No ❑ Sue Gravel <br /> 1 I► <br /> C'ihle ❑ Air ❑ Diameter of boreC, � �(� - <br /> Other ❑ Bucket 0 Packed frmm /O to_„firt - <br /> (7) CASING INSTALLED (8) PERFORATIONS - <br /> Steel ❑ Plastich Concrete ❑ Tvpe of perforation or size of screen - <br /> From To Dna Gage or From To Slot - <br /> ft ft in Wall ft ft size <br /> 0 150 160 12 15 Green - <br /> (9) WELL SEAL r/�e - <br /> 'A'as surface sanitary seal provideda S es No ❑ if yes to depth ft - <br /> ere strati sealed 1��yamst pollution? Yes ❑ No ❑ Internal ft - <br /> Method of seahn Denton�te work sturterl Mara 19 Completed 19 <br /> (19) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water if know ft This well was dnlled under my rurisdictum and this report is true r c best of mar <br /> Standing levet after Hell completio ft knowledge and belief <br /> (11) WELL TESTSyy SIGNED <br /> 1l as well test mnde5 les f� No IN If yes by whom5 (Well Driller r <br /> Type of test Pump Q Bailer ❑ Air lift ❑ NAME- HENNINGS BROS. D IL*LING 0. , INC. <br /> Depth to water it start of test ft At end of test ft (Pers” "PELANDAZEon) VT "'printed) <br /> D*ge�___gal/min after-_--hours yy Water temperature Address _ �� <br /> 1 analysis made° les ❑ No IN If yes, by whom? City MODEST01 CA _Zip w <br /> is electnc log made 1 es ❑ No JX If,es attach copy to this report License No qQjjDate of this repo 1 81 <br /> OWR 188 (REV 7 76i IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED irORM <br />