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# la <br /> ORIGINAL STATE OF CALIFORNIA <br /> Ito not fill in <br /> THE RESOURCES AGENCY <br /> File with DWS DEPARTMENT OF WATER RESOURCES NO. 076262 <br /> of Intent No WATER WELL DRILLERS REPORT <br /> 80-1036- State %4eE[Nilm <br /> Permit -,a or Date 7 Other Well No Q 0 0 <br /> (1.) OWNER \time cJ 3- Mos t <br /> (I2) WELL LOG Total depth 100 ft Depth of completed well 00 ft <br /> Address 29 E. Grantline Rdo from ft to ft Formation (Describe by color character sue or material) <br />' c,tty.-- - Tracy, CA_ _. Zip 0 - 2 toR soil <br /> (2) LOCATION OF WELL (See rnStruetronS) 2 - 10 clay <br /> Counh an oa uin Owners Well Number 10 - 25 sand <br /> Hell address if different from above Koster Rd• Parcel A 2 - 0 clay <br /> O y - <br /> T+innship �� �Ran¢e ,� �--. ectio 30 35 sand � <br /> DiStanc.e from crtte� roads rttimads fences etc- <br /> s 0 ur alb 0 �� <br /> Ferry 0 - 2 sand Sc gravel <br /> 2 _ 78 clay <br /> 2 sand <br /> (3) TYPE OF WORK 2 90 \ cly <br />' +\ew K ell X Deepening ❑ {9� sand <br /> Reconstruction ❑ 9 - t/.0 clay <br /> Reconditioning 0 <br /> Horizontal 11 ell ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> procedures in Item 12) ✓ - t <br /> (4) PROPOSED USE - <br />' Domestic - :9 <br /> Irrigation 11 <br /> Industrial ❑ <br /> Test W ell ❑ <br /> Stock CT <br /> Municipal ❑ <br /> WELL LOCATION SKETCH Other ❑ _ , <br /> (5) EQUIPMENT (B) GRAVEL PACM <br /> Rotary 9 Reverse ❑ ties Nq ❑ Size �n� _ } <br /> Cable Q Air ❑ Diameter of bore - <br /> \ <br /> Other ❑ Bucket ❑ Packed from LL J0...�to q 1 00—ft- <br /> (7) <br /> ft(7) CASING INSTALLED (8) PERFORATIONS <br /> Steel ❑ Plastic ❑ Concrete ❑ Type of perforation or size of screen ' <br /> From To - Dia Gage or From _ To Slot <br /> ft ft in Wall ft ft &Ze <br /> 0 100 6 160 0 100 screen - <br /> (9) WELL SEAL _ <br /> NVas surface sanitary seal provided' ]es C& No ❑ If ves to depth ,%)—ft _ <br /> Were strata sealed against pollutions Yes ❑ No ❑ Interval . Vit. - <br /> Method of sealing-- Work started Completed 19 <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth if first water tf know <br /> I16This well was drilled under my tvnsdieteon and this report is true to the bent o{ coir <br /> Standing ]eel after well completion ft l.nnu.lcdge and belie{ <br /> (11) WELL TESTS SIGNED N--J <br /> %%as well test maden Yes ❑ 1o;9 If ies by whom _ (Weil Drilla <br /> Tvpe of test pump ❑ Bailer [ Air lift ❑ NAME Hennings Bros • Drilling CO• Inc. <br /> Depth to nater at start of test ft At end of test, !* Person firm or rn ration) (Typed or printed) <br /> r rge�al/min after h Address 2 Pelanda je Avenue <br /> ours Water temperature �t�t <br /> —1 analvsis niadeD Yes E7 No City Modesto California 7, 6 <br /> 1f ves b< «homyDecOlectnf lot' made'> Yes ❑ 10 If %es attach copy to this report License No__ 2908213 bate of this report L • 23 f C,I <br /> OWR 1eg (REV 7 761 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />