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QUADRUPLICATE iter OF CALIFORNIA
<br />DO
<br />Use to Comply with THE RESOURCES AGENCY / r�
<br />local requirements DEPARTMENT OF WATER RESOURCES No. 1428
<br />Nou,e of Intent No. WATER WELL DRILLERS REPORT State Well No. /
<br />Un.1 Pemlit No. or Dat
<br />Other Well Nu.—/- "—Z 17`_
<br />(1) OWNER: Nllllr Par Country Lstates (12) WELL LOG: Total dentfW—R. Depth of enmPlrted wall I JI R.
<br />Addres. ..� • � in R. hl ft. Fannetlon iDescrihe ha min.. eh....... .1—
<br />City iltlp.V• VS• Zip/V
<br />--
<br />From
<br />Orso
<br />- -
<br />(2)' Ll (Sec instructions):
<br />K%
<br />Ca...a, ��l4QR�li�1 Owwr's Well N,.... her
<br />Well add.... i e of foam nhnee
<br />'1'uwnship ��� Ilnnge rSer1u _ .-
<br />Dislmwe Imnl eilies, mads, rAle a fs, fences, ete. ris� •
<br />west of golf course C Off ift51y
<br />ft. ft. in. Wall
<br />- Z
<br />sari
<br />Oil
<br />12 - 1 .l4
<br />80e
<br />rS�and
<br />1 - Grave
<br />—
<br />ay
<br />3
<br />- rave
<br />305 Clay
<br />or eas ec on
<br />_
<br />5551 '
<br />0
<br />309 Clay & gr,.vel streaks
<br />0
<br />(3) TYPE T OF WORRI
<br />Ne- Well C lh.q, ging ❑
<br />Ileenrttmetion ❑
<br />)h•t Iftioninq ❑
<br />narm'.1al Well ❑
<br />ly.Imrtiull [] (U.vrrihr
<br />drAmol ian mntrrinlx and
<br />pnarduns in Itrl., 1^_)
<br />(4) PROPOSED VSE:0
<br />u....... a ❑
<br />nriga,i„n ❑
<br />I,°',nt"^' ❑0
<br />'Pert Well ❑
<br />x4 ❑
<br />.W.Idrilml
<br />Other []1
<br />6
<br />-
<br />Clay
<br />Ve
<br />- r G ravel
<br />3 rave
<br />75 _ 76 c
<br />- Gravel
<br />tl'.nk .Luta
<br />-
<br />( 1Q) \VATEII LEVELS:1.;
<br />DrytL nl first \eater, it An..111�_..
<br />Studmg I ... I after %ell rua.Jrli , _
<br />�Cslay
<br />% 2 Gravel
<br />k----
<br />1\Tall. I)It11.I.P:If.S 5'I'A'fP:\IISN'I': --_
<br />Thi, urll uu, d.dlrrf undo, a.,, nai..1"""n tad I,,, r„.,I it rnu• In rho Irro ..l nal
<br />I—',11rh;, and l,l/rf
<br />c _ i
<br />a:cru
<br />- (\\ It D'il ) --- --
<br />nn�l1._ Hennings Brost, Drilling Co. Ine.
<br />1 n tion, r r rV .a' all I I'yprvl nr Onnn•dl --
<br />3525p Pebandala eve.
<br />I I'— -.. +Odesto C$..
<br />I - e \ _ 295LSL1I _._ I l.rtr .d n ........
<br />2 0 C
<br />i
<br />- Grave
<br />-,
<br />- gIN
<br />- rave
<br />- 12 Clay &
<br />12 -' 130 Gravel
<br />gra vol streaks
<br />0 - 1 Gravel
<br />& clay
<br />158 rave
<br />WELL LOCATION SKETCH
<br />b5- Q
<br />(St EQUIPMENT:
<br />IIal:,rc ❑ neverre
<br />C:,ble ID At, ❑
<br />Other ❑ nueket ❑
<br />(n) *GRAVEL PACK:
<br />,•er Lr} Na ❑ S�,birdseye
<br />n;nommr.,( Lnrr
<br />Pa,ked fna.. ro —J ,.
<br />71,
<br />-
<br />Igo
<br />rave
<br />Clay &
<br />grave
<br />ay
<br />—
<br />_ Gravel
<br />-
<br />17) CASING INSTALLED:
<br />StIeA 1'hulir ❑ Gaalete LI
<br />(S) PERFORATIONS:
<br />Pyla• ul Vrrh.nitlen ur size ,.I rerern
<br />22 _—
<br />- 232 Clay
<br />2 239 Gravel
<br />From ToDia. C:µe or
<br />From
<br />To Slot
<br />2
<br />- 2 5 Clay
<br />ft. ft. in. Wall
<br />ft.
<br />ft. size
<br />e2
<br />2 7 Gravel
<br />-
<br />—
<br />3
<br />_
<br />305 Clay
<br />495
<br />5551 '
<br />0
<br />309 Clay & gr,.vel streaks
<br />0
<br />- vel
<br />IU) WELL. SEAL, y
<br />nud:.cv ..... ae;J pravtdcd/ Te.
<br />//��
<br />N., ❑ II , .. e. deplhAL_ it.
<br />0 C a
<br />12
<br />3 rave
<br />We, strata sealed,gaiast Imnam
<br />tii2 Yes C] N,, LI ... cnal_- It.
<br />Nteduxl of sraWl.• 30~ rnnfjurtAT nape eleRnt __
<br />tl'.nk .Luta
<br />---
<br />__Ifl, I:.nu Plrted_ .. 1:)._...
<br />( 1Q) \VATEII LEVELS:1.;
<br />DrytL nl first \eater, it An..111�_..
<br />Studmg I ... I after %ell rua.Jrli , _
<br />__ - .—.ft.
<br />li.
<br />1\Tall. I)It11.I.P:If.S 5'I'A'fP:\IISN'I': --_
<br />Thi, urll uu, d.dlrrf undo, a.,, nai..1"""n tad I,,, r„.,I it rnu• In rho Irro ..l nal
<br />I—',11rh;, and l,l/rf
<br />c _ i
<br />a:cru
<br />- (\\ It D'il ) --- --
<br />nn�l1._ Hennings Brost, Drilling Co. Ine.
<br />1 n tion, r r rV .a' all I I'yprvl nr Onnn•dl --
<br />3525p Pebandala eve.
<br />I I'— -.. +Odesto C$..
<br />I - e \ _ 295LSL1I _._ I l.rtr .d n ........
<br />_
<br />(11) NVELL TESTS,
<br />(v���.����,��,��
<br />N'-: II t I I + 11. No ❑ 11 >•.. 1 i n' }yp}�{yy11y$,
<br />d ix I tot ' m, I nailer a Air I.It ❑
<br />II I ll t "atI 11 Aar! I.f Iesi_ !II At nal d - test . 11
<br />Ch' a.'al ,III,II\fli Ill llle� 1'� – N,1� II ,, ., II' 'll •�
<br />log nurdr'+ 1 Nn L-1=1111 11..: n I ps L, Il' . rep...
<br />DWR 180 ,REV e.>a. IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM
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