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'ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> "le with DWR DEPARTMENT OF WATER RESOURCES No, 36176 <br /> of Intent No. WATER WELL DRILLERS REPORT State well No. <br /> Lk,.,P«•nit No. or Date Other Well No — <br /> ri <br /> YVNER: `c11'e 12) WELL LOG: Total depth ft. Depth of completed well ft. <br /> Address 1051 bL Airport Way from ft. to ft. Formation (Describe by color, character, size nr material) <br /> tStaLton, Cal i��rnia Zip - <br /> LOCATION OF WELL (See instntctions): C <br /> (:rnnty <br /> San.—ina ii..n Owner's Well Number s <br /> "'ell address if different from above 132 - 1 �4 nlay <br /> „unship Range _—Section 134 - 140 course Arid & gravel <br /> Distance from cities, roads, railroads, fences, etc. <br /> (3) TYPE OF WORK: <br /> New Well C] Deepening 3: <br /> Reconstruction ❑ <br /> Reconditioning ❑ _ y <br /> Horizontal Well ❑ — <br /> Destruction ❑ (Describe — <br /> destruction materials and <br /> r procedures in Item 12) _ <br /> (4) PROPOSED USE: <br /> Domestic ❑ 1 — <br /> -_ Irrigation cc _ <br /> TIndustrial ❑ <br /> Test Well ❑ — <br /> �.�/ Stock ❑ I — <br /> MunicipaI ❑ <br /> WELL LOCATION SKETCH Other ❑ — <br /> i) EQUIPMENT: (6) GRAVEL PACK: — <br /> Rotary Z Reverse ❑ Yes ❑ No ❑ Size — <br /> r able F7 Air ❑ Diameter of bore — <br /> Ither ❑ Bucket ❑ Packed from to ft. <br /> 'T' CASING INSTALLED: (8)•PERFORATIONS: — <br /> Steel ❑ Plastic ❑ Concrete. Type of perforation or size of screen <br /> Froin To, Dia. Gaffe or From To Slot - <br /> ft. ft. in. Wall ft.- ft. size - <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes ❑ No ❑ If ,yes, to depth ft. — <br /> 4'ere strata sealed emAiust pollutiun? Yes u No 1" Interval ft. — <br /> '"Sllethod of sea",, Work started 19 Cumoleted 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> depth of first water, if known <br /> n• This well was drilled under my iurisdfetfun and this report is true to the best n% nor <br /> itundina level atter well completion rt. knnwlcdge and belief. <br /> `111) WELL TESTS: SiG?JED <br /> 14'as well test made? Yes `, No ❑ If yes, by whom? (Well Driller) <br /> ,yT. .t test Pump i i Bailer i i Air lift ❑ 7. (t AT .�C� -� � <br /> NAME__ a i__e__._T� <br /> Depth to aster at start of test ft. At end of test ft Per on, firm,nr�nrpnmtinn 1 r T;:p nr pun e ) <br /> `v' ' uze gal/min after hours Water temperatureAddress <br /> (, — al analysis made? Yes " No ❑ if yes, by whom? C — - --_ -___7 — Zip <br /> -lie lot; made? Yes ❑ No '1_ If yes, attach copy to this report License No. Date of this report <br /> +�+ <br /> .+o T oso <br /> .—d !REV. 7-781, IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM ♦36th-9507-765tH aUc, <br /> r <br />