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RIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY filI�o' 076041 <br /> e with DWR DEPARTMENT OF WATER RESOURCES <br /> ,,tent Nr+ WATER WELL DRILLERS REPORT Stitt, Well N" o 2S 0s�27 3 <br /> Other %%ell No <br /> it N mit No or Dite j <br /> 1 OWNER N1n,e Don Most (12) WELL LOG Ti,tif do pt 1 0 ft Depth of completed t,ellO!t <br /> 8691 A lmend ra from ft to ft Formation (De,crihe b% u+lor char ictcr site or nt iters rl) <br /> dress 0 T O S 01 <br /> Tracy Ca. <br /> zip - <br /> - 2 Cla <br /> 1) Li a I�bNEOUELL (See instructions) 2 - Cl ^tiard <br /> unh Owner s hell Number — Sante grave <br /> dl address if different from tho%c ay --7 <br /> Vf � <br /> %n5htp O S S R1nf e 05 Secba JJ u e r <br /> 8 0 11th St <br /> an <br />�atance from titres roads rlilro ids fences etc Q1 l <br /> S .W. corner of 11th St. & Cabe St. - 8 � <br /> Tra cy al - S ,yid & gravel <br /> 8 - 1 Cla <br /> (s) TYPE OF WORK 134 1 \ Sand & ravel <br /> New l%elf X Deepening ❑ �} 150 Cela <br /> Reconstruction Q J <br /> ReLonditlomng ❑ r` — _ <br /> flonzontal %%ell ❑ — <br /> Destructiob ❑ (Describe — <br /> destruction materials aAd _ <br /> procedures in Item I°) — <br /> (-I) PROPOSED USE,yyr,� - <br /> Domestic — <br /> lrrn,ltlon ❑Industrial ❑ <br /> Test %%ell ❑ _ <br /> Stock ❑ <br /> Mumcipll ❑ — <br /> WELL LOCATION SKETCH Other ❑ — <br /> 5) EQUIPMENT E(161,) EL PACKRoofingRot in fie,ene No ❑ Sizerhle ❑ Air bore)they ❑ Bucket _. a--tort — <br /> 1 CASING INSTALLED (R) PERFORATIONS <br /> steel ❑ Plastic Concrete ❑ TN pe of perfnratton or size of screen — <br /> From To� ,Dia Gage=or FTor To SlOt - <br /> {t ft' m Wall ftt`�� ft size' - <br /> 0 1 0 160 1 0 1 0 screen - <br />(9) WELL SEAL ^ <br /> 11 t5 ,ixrf1CL binitln seal provideW )C% No fl if Its sir depth Q ft — <br /> t\cre ,trot celled 1F,aenst pollotion� lei © No ❑ Intent] ft 19 <br /> x1tthod of cellin9 Cement \%oil started 1cJ Coinplrted <br />(10) WATER LEVELS N'1 ELL DRILLERS STATEMENT <br /> 1)epth of first „iter if knot~ ft This wcll mas drilled under ml! lismeliction reucl thil epurt n trur fn 111f In"r n/ mef <br /> {� ft knouledgt find belief <br /> St tndtnl, level tfter Hell completion LL <br /> (11) WELL TESTS N Stc�r u <br /> (i%cl) Driller) <br /> 11 i% sell tc,t mtde" Yes F1 No LX If NLb h, %%hunt' Air lift ❑ — --_ M B OS. Drillin Cor jne p <br /> 1,pr. of te,t Pump ❑ Btiler ❑ NAME— n <br /> f At c fid of Lust ft �ne ony�frny "n�l' rtE ) ye o°r pnntcYll <br /> ]IcptFe to µntt.r at start of tetit—_��—t C i' 1 Q - <br /> I l±e�-6a1/into nfter�..�hours ii iter tempernhirc <br /> Addrecs b <br /> Modes'tok Ca . Date o!this report z, <br /> �,ic11 anll�sic made, les ED Nil if Les b, Nhoni0 <br /> Cih 12-81 <br /> 1%1% cli.c[nc last rnadea le% © Nn If se, stttich cop% to this report Licence No <br /> UTIVELY NUMBERED FORM <br /> t7WR 188 (REV 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSEC <br />