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e STATE OF CALIFORNIA 11 <br /> ORIGINAL THE RESOURCES AGENCY Do not fill 1n <br /> File with DWR WATER DEPARTMENT <br /> WELL DRILLERS REPORT N0. a 0 9 1 ` <br /> ee'of intent No Yale litre 11 No <br /> .oeal Permit No or Date ()flit r Nk ell No —a—aso—TIEZ <br /> (1) OWNER Name (12) WELL LOG Total depth ft Complcted depth ft <br /> Address from ft to h Formation (Dec(rtlx b% color character size or material) <br /> City zip <br /> (2) LO TIO O WEf,L (See Instructions) - <br /> Count) Owner s Wt 11 Number <br /> Well address if different fro above <br /> Township Range - Section <br /> Distance front cities roads railroads fences etc -r <br /> (3) Ti PE OVORK T <br /> New Well Deepening <br /> t Reconstruction ❑ <br /> "W447b'f Reconditioning ❑ <br /> Horizontal Well ❑ \ <br /> i Destruction ❑ (Describe - <br /> f'S t w destruction materials and pro- �- <br /> ' fv` 3 cedures in Item 12) <br /> a ^ ' (4) PROPOSED USE, <br /> C <br /> Domestic ❑ � _ _ _ r <br /> Irrigation ❑ _ <br /> Industrial ❑ <br /> Test Well ❑ Y <br /> Municipal © _ <br /> e Other _ <br /> WELL LOCATION SKETCH (Describe)!"`'/1`df — <br /> (5) EQUIPMENT (6) GR4V PACK _ <br /> Rotary Reverse El - Yes Ko ❑ size <br /> Cable ❑ Aar ❑ Diameter of bore r r Y <br /> Other ❑ Buclet -F_3 Packed fro <br /> (7) CASING INSTALLED �� (B) PERFORATIONS — <br /> Steel ❑ Plastic {� ncrx re Type of perforation or size of sd-rreu <br /> From Ti)r Dia Gage or Vr , Tor - <br /> ft ft tp Mall It ft size - <br /> (9) WELL SEAL /fJ Was surfacY sanitary seal prm ide&' les ,�,�A'a ❑ if)i s to dt pth /' ft — <br /> Were strata waled al,alri% p tillutton? le% L. No I lerval�� ft <br /> Method of Sealing Work start(d ]tl f ornplctcd 19 <br /> (10) WATER LEVELS / WELL DRILLERS STA'i EMENT <br /> Depth of first water if known It <br /> Tho rlrcfl ua 1f(d rrn[frr r(iu 1unultclwn Hurl th15 r[fwrt i% tru( to I&Standing lev(l aftt r well cY)nipl(tion ft 1x st of m no rdgr unit 1x lu f <br /> (11) WELL TESTS Sign(d <br /> Was W(II tett MAC Its ❑ No [I If yt% In whomII Drill[r <br /> of lest Pump ❑ Bail(r ID Air lift ❑ NAM$ SPECTRUM E ORATINr INC. <br /> to Water at start[)I tc5t Il M end of t(%t ft {Per%on firm (ir torpi(iratitan)(Typed or pnnteti) <br /> 1)(schargc gal/min after hours Watertenipxratun Adclres% 2625 E. MYRTLE STREET <br /> ChemrcaianalysninjdeP le% ❑ No 171 If yds by whom+ C t1) STOCKTON r CA /IP 95205 <br /> Was electric log made les ❑ No ❑ If y[s,attach copy to this report Lac(ust No 512 268 Dal( of this r(port <br /> DWR 186 tREV 12-Bel IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />