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OR INAL STATE OF CALIFORNIA Do not fill in <br /> TFIE. RESOURCES AG=ENCY ��. 154216 <br /> !e with OWR DEPARTMENT OF WATER RESOURCES <br /> of Intent No WAFER WELL DRILLERS REPORT State Welt No <br /> oafner qct f <br /> Permit Na or Azte <br /> permit Other Well No 6, .� <br /> (1) OWNER N1me Doug Wilson Pump & Irrig. Sys. (12) WELL LOG ? 35� �7q � <br /> r� Tot11 dep t Depth of completed wo1lL 1 2-ft <br /> Address 0. Box SDG from ft, to ft. Formation (Describe by calor character size or materfll) <br /> city , C zip 9 5 3 7 5 <br /> (2) LOCATION OF WELL (See instruebons) <br /> Coanty LOW <br /> a n J o e u i n Ownces Well Number A <br /> IF di11000 W. Clover 30 - 40 Clay <br /> Wali address different from�bovo I� C <br /> TawnsbiP T i a C� ;;�nge Sectlo 40 46 Sand <br /> Distance Etom cutter roads, railroads fences oto 114 1 West- of, <br /> 46 200 CIat . <br /> MOO07 Grai�e;south side �. ay <br /> NN <br /> (3) TYPE OF WORKNew ]Yell)b Deepening ❑ <br /> Reconrtruttian © - <br /> Reeonditfoning - <br /> Hunrontal Wall ❑ ` �; �`\ `� <br /> Destruction t] (Describe <br /> ru <br /> destruction ailtorials t <br /> procedures in Mont 101/ <br /> (4) PROPOSED <br /> Domestic �' -, - �. Ni, <br /> 0 <br /> Tel ell f f [J '\�\ N` <br /> St <br /> WELL LOCATION SKETCH ��yr Other /ti Q `f <br /> (5) EQUIPMENT (8) GRAVEL'* ACII, C "&' <br /> �!� - <br /> Rotary Reverse ❑ Yes, No Si S +' i <br /> q q � <br /> C+ble ❑ Air ❑ Dia�tt�tcr of ba ` <br /> Other ❑ Aucket 0 Pack, Flo <br /> (7) CASING INSTALLXD (8) fERPOHAfn k4§,, \ <br /> SICCI❑ Plastic CR Con�rets{ ! Type of too ar�+ite of screwF/ ,t <br /> From Tor Dia GagC- r Frei To 1 Sint ' <br /> ft ftp in Wall ft ��ti� ft <br /> 0 215\ 1&.`11 160 195 215-,-, Scben <br /> (9) WELL SEAT, 3o <br /> Was Surface sanitary seal provided? Yes (1 No 0 If yes, to depti. 5 d ft - <br /> Wore strata sealdl ngatask pollution? Yes ❑ No ❑ Interval - <br /> Islnthod of coca <br /> 8 e n t eJ n 1 t Work start 18 Completed-19— <br /> (10) <br /> ompleted-- - 19 <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first w]ter. If know Q This weR was ddifed under my iurisdictfort and this report 0 true tothe est at my <br /> Standinglevel utter well wmpletto v�._._.—,.. .. <br /> 1 tLµ knotnledge and belief <br /> (11) WELL TESTS Sicarrir <br /> Was well test made? Yes ❑ No ty If yes, by whom? - (\yellDriller) <br /> Typo of test Pump ❑ Bailer❑ Air lift❑ NAmE_ <br /> Depth to water at start of teat it At eTilt,of test_ rt (Person nfirtmy,,or corporation) (Typed or printed) <br /> rge _ daI/min Water;L11e}'itard Address 3525 p C E.L11'!D A L _ AVE - <br /> after-----hours - <br /> t "I analysis made? Yes M O D E S T O C A <br /> Q No CI 1f yes, by oma }Cr <br /> �]h o` ' (ty) 7 Q flR 1 _ into of this repo <br /> . Vas electric log made? Yes F) No nl 1t yes. zttnelS copy to this report License No <br /> nWR 188 tR6v 7 7a) IF ADDITIONAL SPACE IS NEEDED USE IV�J{T CONSECUTIVELY NUMBERED FORM <br /> raT <br /> y <br />