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ORIGINAL STATI;OF CALIFORNIA Do,not in i <br /> THE RESOURCES AGENCY Jii� <br /> File With DWR DEPARTMENT OF WATER RESOURCES No. 185784 <br /> of Intent No WATER WELL DRILLERS REPORT state'Well No ` <br /> ennit No or Date Other Well Nz(_[y� <br /> (1) OWNER Nam (12) WELL LOG Total depth--ft, Depth of completed we1L____ft <br /> Add,.=2& fruin ft to ft Forniatinn (Dcsenbe by color character size or material) <br /> City���� �� <br /> (2) L CATI N OF WELL (see instructions) � ` <br /> Cuun Owner's Well Number <br /> Well address if different from above /2 -5" y � <br /> Towuship�`/ .. <br /> Distance from cities, roads, railroads,fences,etc <br /> t\ <br /> (3) TYPE OF WORK ,7 <br /> New Well ❑ Deepening El �.�•—\ <br /> Recomtsuchon ❑ — �\ <br /> Iiecondehanmg ❑ , _ ''' <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describedestructy — <br /> procedures materials ar�d ' <br /> procedures is Item I2) <br /> (4) PROPOSED USE <br /> Domestic ❑ _ _ <br /> Imgatuin ❑ _ <br /> lndustnal ❑ _ <br /> Test Well ❑ _ <br /> Stock 0 _ <br /> Municipal —WELL LOCATION SKETCH Other _ <br /> (5) EQUIPMENT (6) GRAVEL PACK — <br /> Rotary ❑ Reverse ❑ Yes ❑ N0 ❑ Size — <br /> Cable Q Air ❑ Diameter of bore — <br /> Other ❑ Bucket ❑ Packed fro `tn A _ <br /> (T) CASING INSTALLED: - (8)'PERFORATIONS _ — <br /> Steel ❑ Plastic ❑ Concrete ❑ Type of perforation or sue of screen <br /> From TO Dia Qje-or From j- To Slot <br /> ft. ft. m Wall fib�•� ft. :% sue _ <br /> (9) WELL SEAL <br /> Was surface sanitary sea] provided Yes ❑ No ❑ If yes, to depth------ft <br /> Vlere strata sealed against pollution'> Yes ❑ No ❑ <br /> Method of seal= Work started-19_ Completed -- - 19 <br /> (10) WATER LEVELS WELL DRILLER S STATEMENT <br /> Depth of first water if known _ ft Thu uel] iu ,led under mt,�diett n a thu report a true to the best of my <br /> Standing leve] after well completion h knowled¢e ei�ef <br /> (1I) WELL TESTS :1G, <br /> Goss well test made' les ❑ No ❑ If yes, by whom> Well Driller) <br /> Type of test Pump C Baiter ❑ Air lift ❑ NANI SPECTR EXPLORATION, INC. <br /> Depth to water at start of test ft At end of rest ft (Person,firm,or corporation) ('Typed or printed) <br /> arge - gaIlmin after ��urs Water tempera Address <br /> �1 anal STOCKTON CA 95 05 <br /> yens made? Yes ❑ No ❑ if yes, ley whom' City p <br /> s kit=e lag made:' Yes ❑ No ❑ If les attack copy to this report License No -51226E nate of this report _ <br /> DWR 188 (Rev 7 751 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />