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i <br /> __j <br /> STATE OF CALIFORNIA <br /> �!� �) THE RESOURCES AGENCY <br /> DUPLICATE � Do not fill i)I. <br /> Driller's Copy DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT No. 25291. 0 <br /> tci; <br /> Notice of Intent No. Qy_ State Well No. <br /> Local Permit No. or Date P,—24 f 4: QZ Other Well No. <br /> (1) OWNER: Name " (12) WELL LOG: Total depth2 fl. Completed depth 2 1 Q ft. <br /> Address from ft. to ft. Formation(Describe by color,character, size or material) <br /> City T Y'ci C V r,-_1 ZIP C Z � — ) S <br /> oil <br /> 1. <br /> (2) LOCATION OF WELL (See instructions): Vin' — <br /> County San J Q a�g 1 n Owner's Well Number — t P- <br /> Well address if different from above 2 2 1 — 7t <br /> Township Range Section C; — F 2 ( " <br /> Distance from cities,roads, railroads, fences,etc. B n I i F C tn t,e q 4 3 — 4 6 1 r ` <br /> 4 G — 55 Graval <br /> 1011) <br /> (3) TYPE OF WORK: C,4 — 7 L 2 c tr <br /> New Well EX Deepening ❑ — ) t <br /> r <br /> LV- <br /> Reconstruction E:1 <br /> Reconditioning ❑ 6. <br /> j Horizontal Well ❑ Xx <br /> — 5! <br /> Destruction ❑ (Describe — �! <br /> destruction materials and pro- <br /> cedures in Item 12) 179- 1 <br /> i - <br /> (4) PROPOSED US t <br /> Domestic <br /> — r <br /> Irrigation <br /> Industrial ❑ _ <br /> Test Well O ❑ i• <br /> Munici ❑ <br /> O ler <br /> WELI. LOCATION SKETCH <br /> (5) EQUIPMENT: tedfrom <br /> AV CK: <br /> Rotary [ Reverse ❑ No S(z <br /> Cable ❑ Air ❑ of bore <br /> Other ❑ IIucke <br /> (7) CASING INSTALLED: (8) PER?0RATIbXS: _ <br /> Steel ❑ Plastic n e Typ f fo 'on or size <br /> From D" Gage or of — <br /> ft. f I Wall t. size _ <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yes No ❑ If yes,to depth ft.Were strata sealed against pollution? Yes ❑ No ❑ Interval ft. <br /> Method of sealing Work startedF0 1) F5 MEL- Completed 19— <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water,if known ft. <br /> This well was drilled under my jurisdictiml and this repo F is true to the <br /> Standing level after well completion 27 ft. best of my knott;led e and belief. � , <br /> (11) WELL TESTS: �1 YtiSi` SJ SLS <br /> Signed <br /> Was well test made? Yes ❑ No R If yes,by whom? (Well Driller) \, <br /> Type of test Purnp ❑ Railer ❑ Air lift ❑ NAME I - <br /> Depth to water at start of test ft. At end of test ft. Per ,firmor <br /> son , corporation yped or printed <br /> Discharge al/min after hours Water tem J"''2`h ���I A U D X I j A V F g temperature Address � <br /> Chemical analysis made? Yes ❑ No E� If yes,by whom? City I,I WDA S T Q, CA ZIP 9 2 5 6 <br /> Was electric log made Yes L1 No If yes,attach copy to this report License No. 2(-,'n 21 i Date of this report <br /> DWR 188(REV. 12-88) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 <br />