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-ORIGINAL STATE OF CALIFORNIA Do not fi11 in <br /> THE RESOURCES AGENCY NO 086063 <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> . - -of Intent No R 8 WATER WELL DRILLERS REPORT State Well Nos�i <br />' )ermit No or Date 7 -1 628 - Other%%ell..PW (6 E--2 1rC <br /> (1) OWNER \,mp California Water Service C {12) WELL, LOG Tot,l depth T_ft Depth of completed well ft <br /> Address 347 N• Sutter S • from ft to ft Formation (Describe by color character sue nr material) <br />' City OC On Ca, zip - <br /> 1211 Well— 200'+ <br /> (?) LOCATIONSiaqui�VELL (See instructions) rgell � 4 Fill with ea. ravel to <br /> County •.J1 Owners Well\umber y� <br /> Well address if different from above Below surface,\\concrete material--- <br /> Township <br /> a eriaTownship Range Sectio to surface <br /> Distance from cities roads railroads fences etc Pa C i f Z c Ave. & <br />' to kton west side <br /> nf _ = \\> <br /> o th of Longview Ave. <\ <br /> (3) TYPE OF WORK i7 \� <br />' Neu 1%ell C Deepening C <br /> Reconstruction ❑ \� `\i� <br /> Reconditioning ❑ `�� - - �1 \\' <br />' <br /> Horizontal %%ell ❑ �♦ = w �\ - <br /> Destmction X (Describe ���• - <br /> destruction materials and <br /> procedures m Item L?) <br /> (4) PROPOSED USE - <br />' Domestic - <br /> Irrig2ton <br /> Industnal Z, - <br /> Test tt ell ❑ <br /> Stuck {]' <br /> municipal ❑ <br /> WELL LOCATION. SKETCH Other ❑ <br />' t5) EQWP%LENT (6) GRAVEL-PACK = <br /> Rotan ❑ Reverse [] Yes ❑ \o�❑ Sue <br /> C ible C Air ❑ DZameter of bore - - <br />' Other ❑ Bucket ❑ Packe�from to - �r T = <br /> I-> CASING INSTALLED (f)) PERFORATIONS <br /> Steel ❑ Plastic C] Concrete Q Ts pe of perforation or sme of screen <br />' Froin To — Dia Gage+br From \ To` Slot = <br /> Et ft in Wall ft ft size <br /> (9) WELL SEAL <br /> "as surface slmtary seal provldedy Yes ❑ No ❑ If ves to depth ft <br /> %%ere strata scaled against pollution? Yes Q No ❑ Inter i It - r <br /> �lethud of seahn %%rick sltrt>d 19 completed,_19- <br /> (10) WATER LEVELS N1 ELL DRILLERS STaTE`IE\T <br /> Depth of first water if know ft This u.ell uas drrllcd under nay rurisdretinn nnddt is retort i5 foie to bent of my <br /> Standing lesel after well completion+ ft knnuledge and a cf / r <br /> (lI) WELL TESTS Sic\En r ^ _ J _ � r <br /> %%i, «ell test mide� Yes C No Q If ses bs whom? (%4 ellDnller) <br /> Ts pe of test Pump CJ 13-tiler ❑ fir lift Q .. `-00E Hennln s Bros. Dra.11l g Co. , Inc. <br /> Drplh to water at start of lest Ft At end of test It (Person firm or cnrpor-ttion) (T%ped or pnnted) <br /> Dia-hargc gal/mor after hours Water temperature JLddress �52 5-_-_Pelanda le Ave• <br /> 4 1 analysis made', Yes ❑ \o ❑ If yes by whom"- City Modesto, Ca-• Zip 9 53 50 <br /> %,s electric ]n>; made° Yes ❑ No ❑I If ses ittach cops to this report License\n nate of this report_,! a,:�,�!�� <br />' DWR 18B tRrV 7 gal IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> se <br />