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ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> File with DWR DEPARTMENT OF WATER RESOURCES No 150868 <br /> Of Intent No WATER WELL DRILLERS REPORT <br /> y �L 'Atte Well "'oa <br /> Pc unit No or DnOte u 1 U <br /> Other XN ell No �17 — <br /> ( 1 ) OWNER \,,m, (13) WELL LOG nn <br /> }c �np Tntai dept}>_.��#t Depth �>{�nmpleted sveEE_�l�,ft <br /> lddresti 2 1LSiLsnn _ tram ft to ft Form ttion (Describe by color ch trtt ter size or inaterial) <br /> CaN 6 - <br /> Lip <br /> (2) LOCATI ELL (SU or >neom 15 - 20 Snna <br /> ner s Well Number 20 32 Clay <br /> – <br /> Vvell iddre%,�sif�different from above 2 Sand <br /> y <br /> Townships� Ranve O!i` __S.,. 2 - 220 cls <br /> Dostince from cities roads rulruads fences etc 220 - 225 Sand <br /> 22 - 235 Cla <br /> 2 - 240 Sand <br /> 240 - 245, , Clay <br /> (3) TYPE OF WORK 245 :' 270 - Sand <br /> New Well] Deepening ❑ 270 0 Clay <br /> Reconstruction ❑ 1E j0 - '465 Black sand <br /> Reconditioning ❑ <br /> Horizontal Well ❑ _ <br /> Destruction ❑ (Describe 6 $O <br /> destruction materials and 10 <br /> procedures Shale & <br /> rn Item 13) �f – oO -Clay <br /> (4) PROPOSED USEy- - <br /> Domestic y �f _ <br /> .rnl;ation Li – <br />� � <br /> Industrial ❑ <br /> Test Well 0 <br /> Stock 0 _ <br /> f Mumc;p it ❑ – <br /> WELL LOCkTION SKETCH Other Dairy 01 – T <br /> f5) EQLIP%IENT (6) GRAVEL PACK _ <br /> Rotary Reverse ❑ Iesk No ❑ Scz <br />:.able ED Air ❑ Diameter of bore It _ <br /> Other ❑ Bucket C:] P8cked from t-oo tn-4�O _ <br /> i) CASING IV STALLED (8) PERFORATIONS _ <br /> steel ❑ Plasticyc Concrete`❑% Type of perforation or size of screen -7," <br /> From To, Dta Gage-or FEUM ` To �� Slot, <br /> ft ft. in Wall ft��� ft / ISze <br /> 16o 44V 4 8&, - <br /> �;� <br /> 9) WELL SEAL - <br /> Nas surface sanitary seal provided' YeYO No ❑ If ves to depth I C)Q ft <br />+Vere strata sealed against pollution> Yes [] No ❑ Interval ft _ <br /> Method of sealin Work started_ 19 Complet 19 <br /> 10) WATER LEVELS WELL DRILLERS STATEMENT <br />]epth of first w-iter if known, It This well was drilled cinder iml 1urtsdretron and this report is trice to the belt of rnp <br />,tanding level after well completion ft >nowledge and belief <br /> 11) WELL TESTS ,SIC\ED <br /> V is well test m tde' Yes ❑ No ❑ If vvs by whom" (Well Dnller) <br /> ype of test Pump ❑ Bider ❑ -kir lift ❑ <br /> \AVt$_ <br />)epth to water it .+tirt of test ft At end of test-ft (Person firm or corperr'ttlon) ( ped nr pn ted <br /> °11/riun after---hours Witer temperature Address 300 S. <br /> 'l <br /> -al an ilvsls madeP Yes :j No E3 If ves by whom" Cit, _ Turlos�k�,-_ C-a17i d?– zip�Q 5180 <br /> V n electnc, lor. mide> Yes ❑ No ❑ If les attach copy to this report License Nn 0421- Date of this report <br />)WR 188 [REV 776) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />