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ORIGINAL STATE OF CALIFORNIA DO not fill in <br /> THE RESOURCES AGENCY <br /> le with DWR DEPARTMENT OF WATER RESOURCES NO. 219475 <br /> tent No WATER WELL DRILLERS REPORT State Well No <br /> 4Wnnt No or Das'C W ri e r 9 0 t p e r 1 t Other k ell No OZ S�.-� �_f <br /> 1) OWNER Name M & M Builder Supp1y (12) WELL LOG Total depth..lL0--ft Depth of completed "ell 12 1ft <br /> ddress P . O . B o X 1 1 0 7 from ft to h Formatrnn {Descnbe by moor character size or matennl) <br /> Tracy , Cazip95376 0 - <br /> 2) LOCATION OF WELL (See instruetiom) 5 10 Sand <br /> nunh Ouner c Well Number <br /> ell address if different from ahove <br /> iµnship T r a c y �ltan),e Sector 29 - 35 Clay <br /> listance from cities roads railnrtds fences, etc South weSt Cornei 35 - 45 Sand <br /> 45 60 Clay <br /> 60 - 75 Gravel <br /> 75 - 108 Clay <br /> (3) TYPE OF WORK 108 -,-'119 Gravel <br /> Neµ V-ell & Deepening ❑ 119 - 170 Clay <br /> Reconstruction ❑ — ti <br /> Reconditioning ❑ — <br /> Horizontal R ell ❑ — <br /> Destruebon ❑ (Describe <br /> destruction materials and <br /> procedures in Item 12) — <br /> (4) PROPOSED USE��,C[, - <br /> Domestu: L11 <br /> Irrigation ❑ — <br /> Industrial ❑ <br /> Test Veli ❑ _ <br /> Stock U <br /> Municipal ❑ — <br /> WELL LOCATION SKETCH Other ❑ <br /> 5) EQUIPMENT (6) GRAVEL PACK Sand <br /> totary [x Reverse ❑ Yes [X No ❑ Srze G r <br /> ible f-713 II Air ❑ Diameter of bore r� — <br />)ther El Bucket Fl Packed from 50 t.__—1 21 Ft — <br /> 7) CASING INSTALLED (8) PERFORATIONS <br /> teel ❑ Plastic EX COnlrete 0 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 /> 0 121 8 160 101 121Screen - <br /> 9) WELL SEAL <br />%N as sarf+ce sanitary sea] prosided;' les '{X No ❑ If ves to depthF1 Q ft -- <br /> N' cre strata ceased al, t o11 it ' les ❑ No ❑ Intenal� Ft — <br />-dahod of sealing Tse den Mork start u 19 <br /> completed --_19 <br /> JO) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water if knoµ It This well: was dolled under my jurisdiction and thrs report is true to t best of mit <br /> 5t indiag leve] after u elI romplehnft knowledge and beftef P <br /> 11) WELL TESTS SICKED \ h� <br /> 1'i + well test made' les ❑ No if yes by whom, (Weil Driller) <br />]s ie of test Pump ❑ Bailer ❑ Air lift ❑ NAME H E N N I N G S BROS . DRILLING CO . . INC . <br /> Depth to water at start of test ft At,�i� of,test^ ft Pe fi n ati n) Typed or printed) <br /> �en after i fir -4 ��„ss 3 5 2 P L�tr�V�rel� �l V� . <br /> Dichours WAter tem rdhiW Cityl cc ❑ No I If yes by whom City M0QEpST0 ales ❑ No ISd1 If yes alta&Eapy to thig "ort se No 2 9 0 O 13 Date of this repo <br /> DWR 188 (REV 7 '161 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />