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VRIGINAL STATE OF CALIFORNIA DO not fill to <br /> He With DWR THE RESOURCES AGENCY p� <br /> DEPARTMENT OF WATER RESOURk.,2s No. 106275 <br /> t ,of Intent No WATER WELL DRILLERS REPORT <br /> j Prmia No or Date 78-118 5 State Well No <br /> Other Well Nn <br /> OWNER 'la,,,, alls (12) WELL LOG, <br /> l, Total depth `Ft Depth of completed well ft <br /> 16N E w iters Rd front ft to ft Formation (Describe by color character stye or material) <br /> B ch Cam California Zip - Sand Leam <br /> 12' ) LOCATION OF WELL (SLc tnstntctiom) 3 14 Sand <br /> ('ililita_ Owners Will Number 14 — <br /> 22 rl my <br /> 1,L11 <br /> address if different from above 22 _ 34 Sand W cla streaks <br /> n,hrp Ran};r~-. „.Sectio 34 40 Cla <br /> Divtalice from cotes mads railroads fences, etc 40 70 Cla, w sand streaks <br /> 70 - 98 Course sand w clay streaks <br /> 98 - 134 Brnp& Blue clay w sari <br /> (3) TYPE of rvoRI: - <br /> streaks <br /> New Well 1$ Deepening ❑ <br /> Reconstruction 11 _ \\ <br /> Reconditioning ❑ _ <br /> Horizontal Well ❑ _ <br /> Destruction ❑ (Describe - <br /> destruction materials and <br /> procedures rn Item 12) _ - - <br /> (4) PROPOSED USE - <br /> Domestic 9 _ <br /> Irrigation ❑ _ <br /> Industrial Q _ <br /> Test Well Q _ <br /> Stock ❑ _ <br /> Municipal Q _ <br /> WELL LOCATION SKETCH Other 0 _ <br /> UI:PMEN'T (6) GRAVEL PACK _ <br /> Rot try Ix Reverse ❑ Yes>m No ❑ Size _ <br /> hle Ij Airn <br /> ❑ Di'ameter of bore,her ❑ Bucket Q Packed from J ttr 134 f <br /> t <br /> (71 CASING INSTALLED (8) PERFORATIONS <br /> el Plastic ❑ Concrete 0 Type of perforation or size of screen <br /> Froin To Dia Gage or From To Slot " <br /> ft. ft In Wall ft ft Size0 95 _ <br /> /all <br /> (9) WELL SEAL <br /> surface sanitary seal provtdeda Yes ❑ No ❑ If yes, to depth-------___ft <br /> m strata sealed agatnat p41llutton? 'Yes ❑ lNo r Inter a _ft — <br /> Method of seahng <br /> Work it-irted 19 Completed 19 <br /> 0) WATER LEVELS WELL DRILLER'S STATEMENT <br /> pth of first wzter tf kno%n-- ---� This well was rlydled under ntri mrrsdwtion and this r <br /> riding te,el tfter well completion— (t knonledge and behc/ errnrt a tree to the best of >ntl <br /> (1I) WELL TESTS Sic\8D <br /> twell test mule? Yes ❑ No [IIF ves by whom4 (Well Driller) <br /> of test Pump ❑ B Biller E; Air lift r'-] iV ME NO <br /> h to nater at start of test _ft At end of test ft Persop,�firm a (d7g ratwn) (Tvped or printed) <br /> Dtschurge-- -- �tal/iriin attar ,huun �6aLer ti:niperatute <br /> Address P.60—1305 V L� <br /> qd analysts made? Yes Ci Stockton, Cali ornia 95 Ro <br /> t] do Q If }es by whom? b zip <br /> electric tog made+ Yes ❑ No C1 If ties attach copy to this report License No ate of this report <br /> o-sa ,REV 7 701 IF ADDITIONAL,SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />