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STATE OF C.AUrORNIIA <br /> THE RESOURCES AGENCY DO not fZII in <br /> MIGINAL. DEPARTMENT OF WATER RESOURCES <br /> a *th DWR WATER WELL DRILLERS REPORT N4. 252838 <br /> 9 State Well No <br /> Lice of Intent No <br /> �a X814 3 9 7 Oilier Well No <br />,ocal Permit No or Date <br /> 7_ <br /> I) OWNER Name (12) WELL LOG Total depth 24 7 -- ft Completed depth�_ft <br /> ddress 1290 Shaw Rd .-- Club from ft. to ft. Formation(Describe by color, character, size or material) <br /> ity qtOrkinn , Ca zip 0 — 3 Top SO 1 1 <br /> ee cos3 — 19 Clay <br /> 2) LOAM69 aT'-W , rsuttin ) <br /> - <br /> ounty Owners Well Number <br /> 2 6 – 48 Clay & Sha <br /> dell address if different from above 48 – 51 Sand <br /> om riship Range Section – !^\ <br />)istance from cities roads railroads fences etc 60 89 Clay <br /> 89 92 <br /> – v <br /> (3) TYPE OF WORK 1 <br /> 21 al <br /> New Well [X Deepening <br /> Reconstruction ❑ <br /> Reconditioning ❑ <br /> n <br /> Horizontal Well Cl <br /> Destruction ❑ (Descnbe <br /> destruction materials and pro- <br /> } <br /> ce(iures in Item 12) n 2 1 S 1� V <br /> (4) PROPOSED US G\ <br /> Domestic 2 3 0 \` <br /> Irrigation Ci`^-- 2 ' 1 \ <br /> Industrial ❑ 3:7`\\ ^47 S a <br /> Test Well ��� 1 E3 `} J <br /> Other ❑ –' – - <br /> f ' <br /> WELL LOCATION SKETC14 �(Describe) – <br /> 5) EQUIPMENT (6)tiGRAVEL PACK Sand & <br /> Rotary Ex Reverse ❑ YeaXj NO ClSiz P <br /> I I <br /> Cable ❑ Air ❑ Diameter of bore <br /> Other ❑ 13orket (] Packed from _ n n to 2-2-5-- ft <br />-� C A4I�,C'1i.S'i ALI ED (S) PERFOR&TIONS — <br />,i�r ❑ Plastic [:�, Concrete ❑ T,pe of r)erfo-ation or sszr of screen <br /> From f o Dia Cage or From To slot <br /> ft ft IIi Wall ft ft � size22 R <br /> – — <br /> �� p – <br /> 9) «'ELL SEAL <br /> Aassurface sanitar?seal pro%sacal' Yes No ❑ Ll yes to depthlogfL — <br /> A'ere strata sealed against pollution? Yes ❑ No ❑ Inter%a] ft — <br /> YSetFicd of sealing Wort,started 19 Completed 19 <br /> 10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> 3eptb of first. ater if known ft Thts well was drilled under my jurisdiction and this report is true to the <br /> ks� nffi Ievel after well co¢pletton 49 ft best of my knowled and belief <br /> -N 5.si <br /> 11 WELL TESTS signed (Well Driver) <br /> yV est n,, c! t Yes ❑ No If yes,by whom? <br /> = Pump ❑ 4-F nailer ❑ Air lift <br /> ❑ NAME � or rin <br /> ed) s <br /> to water at start of_test ft At end of test ft (Person snA or corpora ton) 3 P R p <br /> gal%minafter'- hours 'Nater temperature Address <br /> a �` '" ZIP <br /> 1 analysis made?=Yrs ❑�=No DO' If yes,by whom? City 8 7 <br /> AV ei>x iclog made -__ Yes ❑ No , If vM attach copy to this report License No _ 29 C 8 1 3 Date of this report <br /> i68 t2-B� <br /> IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 66 96355 <br />