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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES O O <br /> WATER WELL, DIULLERS REPORT IVO. <br /> ice of Intent No State Well No <br />' Local Permit No. or Date Other Well No 44wok � <br /> (1) OWNER Name PA17 Indd (12) WELL LOG Total depth245 ft. Completed depth202-- _ft <br /> Address 19098 N MillIz Rd from ft to ft Formation(Describe by color character size or material) <br /> City — Tnrlrofnrrl ZIP 29217 _ <br /> 1 so-11 <br /> (2) LOCATION OF WELL (See instructions) 1 -3 reddish brn clay <br /> County San Jogggin Owner s Well Number 3 —10 hard Dan <br /> Well address if eff ent from above 10 –13 Sand clay <br /> Township Range Section nZ 13 -19 loose sand <br /> Distance from cities, roads, railroads, fences, etc Well 79ft fvnm 19 -53 various sand strata unstable <br /> North fence 60 ft. from NE scorner of home 53 -56 silty clay 't avel <br /> 90 ft from west prop line 56 -83 one inch ave m cls <br /> 83 -90 cla 1 some gravel <br /> e poap (3) TYPE OF WORK 90 -98 brn cla A�l3ttle silt <br /> OT New Well $1 Deepening El 98 -121 brittle dela mostlybrn ela <br /> 1" Reconstruction ❑ 121 -132 bl6cic sand and gravel to 2" <br /> Reconditioning ❑ 132 A4 bin la /^i <br /> 1 V Horizontal well Cl 145 -157\\ coarse- s&nd and pea gravel <br /> Destruction ❑ (Describe15 \\- "brn _clef <br /> destruction materials and pro- 196 -1-205 coarse black sandstone and Aea <br /> cedures in Item 12) 1 <br /> (4) PROPOSED US 205 v_245 -various clays-; . .sand strata at <br /> Domestic - -200 tout g6od sand runs <br /> Irrigation = \ leveling-out at 202. <br /> Industrial ❑ �� – .f, <br /> Test Well \ ❑ r� \ _71 <br /> Munecepa ❑ i <br /> WELL LOCATION SKETCH < <br /> (5) EQUIPMENT Vq GRA Val.PACK �^ '/Z <br /> Rotary ❑ Revers Q m QNo X Stu <br /> Cable :1z] Atr ❑ of bort <br /> Other ❑ Bucket'—F-1 ac#Sedfrom to f! — <br /> (7) CASING INSTALLED \ I (11) PERFORATIONS _ <br /> Steel $1 Plastic ❑ ntiv <br /> hete ❑ Type of Woran or size of screen — <br /> From To Did Gage or Fetom To, , Stot – <br /> ft fig in Wall fL-- --ft size _ <br /> 0 -156 <br /> 16 50 12,2 17 9 <br /> (9) WELL SEAL <br /> Was surface sanitary seal provided? Yes IR No ❑ If yes,to depth 120 ft <br /> Were strata sealed against pollution? Yes ❑ No R Interval ft <br /> Nethodofsealing oTayi ty Uout Work started 19_ Completed Nnv 1 7 .196— <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water of known 1911 ft <br /> This well was drilled under m jurisdiction and this report is true to the <br /> Standing level after well completion 117 ft best of my knowledge and belief <br /> (11) WELL TESTS Signed <br /> Was well test made? Yes [3 No ja If yes,by whom? (Well Driller) <br /> of test Pump ❑ Batter ❑ Air lift ❑ NAME <br /> to water at start of test ft At end of test ft. (Person,firm or corporation)(Typed or printed) <br /> n+rge gal/min after hours Water temperature Address <br /> Chemical analysts made? Yes ❑ No ❑ If yes,by whom? City TIP <br /> Was electric log made Yes (3 No ❑ If yes,attach copy to this report license No 391542 Date of this report <br /> DWR 188 iREV 12-86) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 94 vacs <br />