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. t 8 <br />)RIGINAL STATE OF CALIFORNIA Do not ft16 to <br /> THE RESOURCES AGENCY <br /> th QWR DEPARTMENT OF WATER RESOURCES SIO. 076002 <br /> Intent No WATER WELD., DRILLERS REPORT State Mell No <br /> al Permit No or Date—18-i <br /> Other It ell leo.rJ 3 ✓' '- j <br /> 1 ) OWNER Lame Don Cosi12 WELL LOG 21 <br /> res P.O. BO$ 2b � � Total dep�ft Depth of completed wett1 7OK <br /> from ft to ft Formabon (Describe by color character site or material) <br /> racy, Ca. Z,PO_ 2 o soil <br /> 2} LOQATIO� OF WELL (See instructions) Clay <br /> Chip <br /> ,.__._ an .,,,oaa n Owners Well Number - 9 Sand <br /> ddress rf different from above �'$Qe Q —Ramie-0�E Sectio - ay <br /> bstance from cities roads railroads fences etc Lot C+ New 45GraViEL <br /> Jerusalem Koster Rd .-south of _ 0 C1a <br /> Durham Ferr Rd® west side - Grave <br /> 62 - C y <br /> (3) TYPE OF WORK = Gravel <br /> Neu 14 en x Deepenrmg ❑ Clay <br /> Recoastruchon © _ rave <br /> Reconditioning 0 1 _ 1 <br /> 52 r-1$33E <br /> Horizontal Well 0 -152 162 G <br /> Destruction ❑ (Describe62 _ 215 <br /> �1 C <br /> destruction materials &vd <br /> lay <br /> procedures m item 12z, = _ <br /> (4) PROPOSED USF—;r> <br /> Drimeshc <br /> Irrigation,/r 6 _ <br /> Industrial <br /> , 0 <br /> Test Well 0 <br /> Stock 42" _ <br /> Municipal ( - <br /> WELL LOCATION SKETCH Other 0 <br />>1 EQuTP�tEN"T (6) GRAVEL PACU Roofing \ — <br /> otari Reverse 0 Yes Ig No-0 Size _ <br /> IT <br /> P G Air 0 Diameter of bore <br /> Q Bucket [] Paeked from <br /> i CASING INSTALLED r (8) PERFORATIONS - <br /> I n Plastic EX Concrete ❑ 'Type of perforation or s¢e of screen <br /> rom To r Dia Gage or From, To Slot-, - <br /> ft ft M Wall ft. it s.ze _ <br /> 176 6 16011 0 170 lacreert - <br /> WELL SEAL <br /> s surface santtary seal provided" Yes I No ElIf ves to deptli_Wft - <br /> re strata sealed against pollution les C] No ❑i Interval ^, — ft <br /> etbod of sealm Cement M ork started — 19 Completed 19 <br /> WATER LEVELS WELL DRILLER'S STATEMEI\'T <br /> of first water, if know This well was drilled under my rrinsdiction and this report is true ro the 8err of my <br /> JI)h <br /> ding level after well enmpletio ft knou.iedge and belief <br /> 11) WELL TESTS SIG\ED /J <br /> wuell test made, yes ❑ %a.' If yes b• whom (Well Driller) <br /> t test Pump E3 Bailer 0 Air lift © NAmE Henn n S Bros. Dri 1 Coo In <br /> eater at start of test `ft At end of test _R Person firm or corporation) (Typed or printed) <br /> mal/min after hours water temperatureAddress _1 2 }Pelandale Ave <br /> ,acal anal,sis made yes Q No X If ves bi whomP City_. _Hod e s 1.o o Ci a n Zip 9 5-156 _ <br /> electric log made' les 0 No X If •es; attach copv to this report License No P qn8 i Date of this repo <br /> rt 7-8-al <br /> WR 186 iRt:v 7 76) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I <br />