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GRIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> Pile with DWR DEPARTMENT OF WATER RESOURCES No. 219475 <br /> V..,.,r of intent Vo. WATER WELL DRILLERS REPORT state Well No. <br /> :'ermit No. or Dat9 w n e r got permit OtherWell Nn.pZSQSS <br /> — ���� <br /> ( 1) OWNER: Mame M & M Builder Supply (12) WELL LOG: Total depth_1_L1Lft. Depth of completed wen 12 1ft, <br /> Address P . O . Box 1 1 0 7 from ft. to ft. Fnrmatinn (Describe by calor, character, size or materia) <br /> C:t, Tracy . Ca ip95376 5 Top Soil <br /> 0 <br /> ( ?' LOCATION OF WELL (See instnletioms): 10 Sand_ <br /> �:ounty S_an J n a n l l l n Owner's Well dumber <br /> Weil address if different from <br /> Cabove _ Rd . 26 29 Sand <br /> ;',,.unship T r a C y 0�7 Range 5 G Section 29 35 C 1 a_ <br /> Distance from cities, roads, railroads, fences, etc South West—Corner 35 - 45 S a md. <br /> 45 - 60 C I a ` =;", <br /> 60 - 75 ,Gravel <br /> 75 - 108 '0`1a <br /> (3) TYPE OF WORK: 108 -'119 Gravel <br /> New Well & Deepening ❑ 119 1 F 7 0 Clay <br /> Reconstruction ❑ — � <br /> Reconditioning ❑ — <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and - — <br /> procedures in Item 12)t <br /> i (4) PROPOSED USE: - <br /> Domestic } _ <br /> Irrigation ❑ — <br /> i <br /> J Industrial ❑ - <br /> Test Well ❑ — <br /> Stock ❑ — <br /> Municipal ❑WELL LOCATION SKETCH Other ❑ <br /> 5, EQUIPMENT: (6) GRAVEL PACK: Sand & — <br /> Rotary f:x Reverse ❑ Yes CX No ❑ Size G r a v e I — <br /> Cable C air ❑ Diameter of bore 13" — <br /> Other ❑ Bucket Packed from___5—0to 1-2-1-ft- <br /> CASING <br /> 21ft,CASING INSTALLED: (8) PERFORATIONS:. — <br /> iteei ❑; Plastic q Concrete ❑, Type of perforation ur size of screen <br /> From To Dia. Gage-or Frour. To <br /> ft. ft. in. Wall ft �:' ft. `size. - <br /> 0 121 ,•8 16 0 101 121 n - <br /> 9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes No ❑ If yes, to depth O ft. <br /> Were strata sealed agat pollution? Yes C3No C] Interval ft. — <br /> Method of sealin re m e n t <br /> Work started t)U I y 2 19= Completed 19 <br /> 10. WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known _ ft. This well was drilled under my jurisdiction and this report is true to t best of my <br /> ,�tanGing level after well completion <br /> ft. knowledge and belief. ) <br /> 11 WELL TESTS: SIGNED <br /> W-is well test made? Fes !_ No _ If yes, by whom? (Well Driller; <br /> Tape ,,f test Pump ❑ Bailer Z] Air lift ❑ NAME H E N N I N G S BROS . DRILLING CO , I N C . <br /> Depth to water at start of test ft. A,,,�,,d of�jfst ft Pe u fi , o ate ni Typed or rented) <br /> Di Pbarge mal;min <br /> after__________hours; W.Pi terir'pe,r ess 3525 L 1 X1 V p <br /> c' analysis made? Yes ❑ No If yes, by whom? City M 0 D E S T 0 s Ca Zip 5 ri 6 <br /> ,tris I—( made? Yrs ❑ No If tics, •itta,-R Z- qy Ili this yep6K NO. 290813 Date of-his repo <br /> oWR 188 tREV.7.761 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />