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ORIGINAL. STATE OF CALIFORNIA DO not fill to <br /> File with DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No, 085319 <br /> rf Intent \o WATER WELL DRILLERS REPORT <br /> ernut Nn or Date Stitt 1�'c!I Na <br /> Other "ell Ni 56' Z �– <br /> (1 ) OWNER y,-uu California Welding Welding Supply (12) WELL LOG 80 80 <br /> Address - 817 S• Center St• Tnti] delrtlt^�ft Depth uI completed well tt <br /> from ft to ft Formation (Describe bN color charqcter sve or mntenal) <br /> (,t, Stocktoll, a. zip 0 - Topsoil- <br /> (2) <br /> o soil(2) LOCATIOn' OF ELL (See instruc tions) - 1 Cl <br /> ay <br /> ('sunt% San JJ Da �1�n Owners Well Number 1 - Gravel <br /> ell address if different from ibove – 2 Cla�r� <br /> Tin,nship Ranf-e section 62 - rave` <br /> Distance from cures roads, rulrotd, fences etc California - ou a <br /> Weldm Su ly 1000 E. lith St . - <br /> T ac -i µ <br /> (3) TYPE OF WORK <br /> New «ell X Deepening ❑ { <br /> Reconstruction © _ <br /> Reconditioning U _ <br /> Horizontal Nell ❑ <br /> Destruction ❑ (Describe _ <br /> destruction materials and <br /> procedures in Item 12) – <br /> (4) PROPOSED USE - <br /> i DorneStlC –_ <br /> Irrigation ❑ <br /> Industrial ❑ _ <br /> f � Test M ell ❑ – <br /> Stock [] <br /> Municipal ❑ _ <br /> \)ELL LOCATION SKETCH Other [] _ <br />!a) EQUIPMENT (6) GRAVEL PACK _ <br /> Ratan lieserse ❑ )es 4N \o ❑ Size bird se e – <br />( rble ❑ Air1 1 ti <br /> ❑ Diameter of bore _ <br /> Other ❑ Bucket ❑ Packed front <br /> 0 to 0 ft <br />!r I CASING INSTALLED (8) PERFORATIONS – <br /> Steel 0 Plastic Concrete ❑ Tyrxof perforation or Size of screen <br /> Froin To Dia Gage or From To Slot - <br /> ft ft in 'Fail ft ft size <br /> screen - <br /> 9) WELL SEAL _ <br /> 11 as surface sanitan sci! pro,idcd� )es \u u 11 Nes to depth�0 ft _ <br /> acre strnti sealed 't{.ainst polhttion" )es ❑ Nn ❑ Intend ft – <br />\tctltod of seahn BentoniteM ork starte 19 Complete I9 <br /> I0) WATER LEVELS NN ELL DIALLER'S STATEMENT <br /> f-)cpth of first NNAter if knovin ft Tlirs mill uas drilled undLr mg lrrrndiehon and thi, rtin,rt is trur to tht hest rrf <br /> et imdmg let el atter u ell cumpk tin ft k oau.ledgi acrd belief my <br /> 11) WELL TESTS Sic\ED <br /> 1 is acll test Intde� )e% ❑ tin if sts hN N%houi' t <br /> p (\�cil Duller) f <br /> f s e of test Pump d S tiler © Air lift ClN1N11; �- iS B Dri l in C o. jnc p <br /> • <br /> lc lith to AN Iter it sort of test oS <br /> ft At end of test !t P t firm r c int to (Typed or printed) <br /> " r�-..—;,al"mm nftei hnun Miter tempt rthire Addre.cs 52�` e`�an ale tl ep <br /> intINNIS niadea )es [_II o If Ne\ bs nhinno City Modesto Car Zili 9535+0r�` <br /> nc log m idep )es ❑ I%o I f s es itt is h c 0111 to this report License.No 290813 <br /> Q013 _D rte of this rCpoT 1 1 —2(7�'/ <br />.)WR 188 tREV 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />