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0- 17 <br /> ORIGINAL STATE OF CALIFOANIA <br /> Do not SII In <br /> File with DWIt THE RESOURCES AGENCY <br /> DEPARTMENT OF WATER RESOURCES No, 076263 <br /> of Intent \ir WATER '6)[TELL DRILLERS REPORT <br /> State %%ell \n <br /> it <br /> Permit No or pate _R 0 <br /> Other ell \o •J `^- �•� <br /> (1 ) OWNER \an,r Jim MOs t (12) WELL LOG �9�f��n <br /> tline Rd® Tuta]depth, 9 00ft Depth of completed sell v'tt <br /> Address 29 E• Gran <br /> from ft to ft Forination f Desenbe by color character size or material) <br /> f-it, rd cY s zip 0 - 3 top soil <br /> (2) Lgan oa CATrNr OF WELL (Ser instructions) S cla <br /> Cnunh In Owners dell Dumber _ 2 sand & gravel <br /> %%ell address of different from above Kos ter Rd, , Parcel E 52 - 77 clay <br /> Tognship_ 117-_ Ranpe � Q Sectio y,�,, �+ = sari - grave <br /> Distance from titres mads railroads fences etc 2 0 `s Ulbh ofDurham Ferry $ clay <br /> Ferry - Rd. - 8 sand & gravel <br /> 98 -100 clay <br /> (3) TYPE OF WORK - <br /> '.ew Well QE Deepening ❑ <br /> Reconstruction _ <br /> Reconditioning [� _ <br /> Honzontnl k1 ell ❑ _ <br /> Destruction ❑ (Describe = ~ <br /> destruction mltenals and <br /> procedures in Item 12) <br /> (4) PROPOSED USE - <br /> Domestic <br /> Irrigation <br /> Industrial 0 <br /> Test Well © _ <br /> Stock ❑ _ <br /> Municipal ❑ _ <br /> WELL LOCATION SKETCH Other ❑ _ T <br /> (5) EQUIPMENT (8) GRAVEL PACK _ <br /> Rotary M Reverse ❑ Yes No ❑ Size <br /> Cable (] Air ❑ Diameter of bore it _ <br /> Other Q Bucket ❑ Packed frnm_-_ <br /> (7) CASING INSTALLED (B) PERFORATIONS <br /> Steel ❑ Plastic ❑ Concrete <br /> ❑ Type of perforation or arze of screen _ <br /> From To Dia Gaffe-0r From _ To Slot = <br /> ft ft. in Wall ft ft size <br /> 0 900 960 g0 <br /> (9) WELL SEAL _ <br /> Was surface sanitary seal provided' les f$ No ❑ If yes, to depth_ c) ft _ <br /> Were strata sealed against pul)uhon�, Yes ❑ No ❑ Interval ft <br /> Method of sealtn Cement 14nrk started 19 Complet 19 <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first Kater if know ft <br /> This well was drilled under my Jurisdiction and this report is true to the best tit my <br /> Standing level after cell completion ft knowledge and behef <br /> (11) WELL TESTS SIGNED— <br /> X% � <br /> vp well test made' Yes L \a� If res by wham" (Well Dnl r <br /> hpe of test pump ❑ Bailer ❑ Air lift ❑ -NAME Hennings Bros o Drilling Co. nc <br /> oma` <br /> Depth to .eater �it start of teat ft At end of test ft (Pon firm or coipnrlpon) (Typed or punted) � II <br /> rge. gal/min after_ Noun 14ater temperature Address Avenue <br /> eal analysis madeD Yes ❑ No Z If ,es b} uhnm� Crh Modesto <br /> Cala-f orna` Zip 95356 <br /> electric ]n¢ made les ❑ \n If ses attach urp� to this report License 'ya_ 29o8 3 _ Date of this report Dec. 3 I i 9sc <br /> DWR 188 (REV 7 751 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I <br />