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LIGINAL STATE OF CALIFORNIA Do not fiU sn THE RESOURCES AGENCY e with DWR DEPARTMENT OF WATER RESOURCES No. 216168 Intent No WATER WELL DRILLERS REPORT State Wen No rmtt No or pate Other Well N OWNER Nam M-c C o rai c k & B (12) WELL LOG Total depth� Depth of completed welL1.-7 .ft address P -0 . B o lx 1 7 2 8 from ft to ft Formation (Descn'be by color, character size or material) SUck_t-on . CA zip 0- 30 Brawn-dense cl a 1) LOCATION OF WELL (See trtstructiom) 30- 40 Blue Teen clay o a t! n Owner s Well Number 0 - C 40- 50 B1 u e r e c 1 a w s a n d l e n s county San ell address if different from above ^ S Stockton & Church 5 0- 60 B l u e r E e �Clay wnship 11 N Range 6 E Sectio0_B W 1 stance fnim cries roads railroads, fences,etc 137- 140 Blue 'lc q Clay _ n (3) TYPE OF WORK -� ' New Well X Deepening ❑ R Retomtrwtuin ❑ f Reconditioning 0 - ' Horizontal Well ❑ - Destruction ❑ {Describe S r~1 destruction materials an procedures In Item 12�'� (4) PROPOSED 1 See Map Attached Domestic _ I rny,ahon ❑ - \ "~ ✓ Industrial ` , ❑ 7 Tegt Well ❑ ^\• - Shx.kl Municipal ❑ - �. WELL LOCATION SKETCH •4 Qther MW '� EQUIPMENT (B) GRAVEb\ CK RotaryK) Reverse ❑ Yes IM No ❑✓ Size 3'_ d — ble ❑ Air 0 D0rgp1m of bore 10 528 4J �� her ❑ Bucket ❑ Pat kad from 117 ta` 1 3 7 fit_ �� - CASING INSTALLED �% +� (f)) PERFORATIOIs[`4. Steel 0 Plastic (S Concrete, Q Type of perfoy%"or sive of screen - From To Dia Gas M FroM To Slot ft ft m Wall ft ft c ze - 1C 0 134 - 4 " sch40 127 134 - (9) WELL SEAL �> - tas surface sanitary seal provided les [3 No ❑ If yes, to deptli 117 ft ere Strata sealed a pnrist polluh00 Yes ❑ No ❑ Interval- ft - - - elhod of sealun l L e m e n t Grout Work starter 19 Complet 1t)fopth WATER LEVELS WELL DRILL RS S'TA'TEMENT \of.first water 3f know This tue1l trwr dr Ied ridermyrunsdectton and this report tS true to the heat o} mundmg level after well complerio.. ft knowledge and eine (11) WELL TESTS SICNEf� Was well test made" Yes (D No [3 If yes, by whom' { e13 Dn13er) 3pe of test Pump ❑ Bader ❑ Air lift ❑ NAME DiaMond CQP Dril I -inn Inr epth to .cater at start of test ft At end of test ft (Person, firm, or corporation) (Typed or printed) Tge gal/nun after - - .ours Water temperature Address 10556 P e t u n i a LN 96023 al analysis made? Yes ❑ No ® If yes, by whom? Ctty Palo C e d r 0 CA p as electric Inst made? Yeis ❑ No [9 If >es enach copy to this report License No 512.406 Date of this report 4— 1 g--8 9 DWR 188 (REv 7 lel A"DDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM I