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QUADRUPLICATE -JY- 5 <br /> Use to compiy with STATE OF CALIFORNIA Do not fill in <br /> local requirements THE RESOURCES AGENCY No. 29058 <br /> DEPARTMENT OF WATER RESOURCES <br /> ra of Intent No. WATER WELL DRILLERS REPORT State Well ,N,_ <br /> l:,c t Permit No. or D IS--7&53 Other Well No. <br /> 1) OWNER: Namr (12) WELL LOG: Toro depth-IOL-ft. Depth of c,ampleted wella9i ft. <br /> Address 730 Lexinxton Ave from ft. to ft. Formation (Desenbe by euka. character, size or material) <br /> t in- sLOCkt= Zip - soil <br /> (2) LO�=AII q)N O WELL (See instructions): 10 - 1 blas O es <br /> I Coonts ^^"� Y .�.�r� Owner's Well Number 113 50 Reil C oose roCkS <br /> It"eIl address if different from above gq? 5 I- Rd Clouent +�0 - 0 soft 1 FFXvy,.„ C13 <br /> Township Range Section (70 - 90 Ned. red clay <br /> Distance fens cities, mads, railroads,fences,etc. /si - 110 Hard red Clay <br /> - 145 Hard grey shale <br /> 170 190 Arow sandston,I <br /> (3) TYPE OF WORK: - <br /> New Well Deepening ❑ <br /> Reasnstmcdon ❑ <br /> ,n 1 <br /> Reconditioning ❑ p 7.q - r <br /> Hodzantai Well ❑ - <br /> P50 claY <br /> Destmction ❑ (Describe 750 - 265 Black sandstone <br /> destruction matrrtals and <br /> procedures in Item 12) 265 - 2M clay <br /> (4) PROPOSED USE: 270 - 272 QQbblest <br /> Domestic Jt 272 - 295 Black ca.. •i0 <br /> Irrigation f[) 295 - 340 Clay - . <br /> �f Industrial ❑ - <br /> Test Well ❑ - <br />` Stuck ❑ - <br /> f- /'• .^ s' MunivipRl ❑ _ <br /> 1 <br /> WELL LOCATION SKETCH Other ❑ – <br /> (B) EQUIPMENT: (6) GRAVEL PACK: <br /> Rotary Reverse. ❑ Yes ] No ❑ Sizet <br /> I' Cable ❑ Air ❑ Diameter of bore 12SIS - <br /> Other ❑ Bucket Packed from to = <br /> (7) CASING INSTALLED: (9) PERFORATIONS: <br /> Steel ❑ Plastic X) Concrete ❑ TYIa' of perforation or size of screen <br /> From To Dia. Cage or From To Slot - <br /> ft. ft. M. I Wall ft ft. size <br /> N 160 <br /> 2 <br /> M - <br /> i <br /> (9) WELL SEAL: 143 123 ~ <br /> Was surface sanitary seal Provided% Yes <br /> , No r1 if pc s, m depth50 <br /> Were strata sealed aeainst pollution? Yes V1 Nni❑ Interval n. - <br /> Method of sea" Work started_ 19 Completed 19 <br /> (10) WATER LEV LS: WELL DRILLER'S STATEMENT: <br /> Depth of lust water, rf know,, R. This .,It uma drilled uaG-r my i,kc/hIt... cul fl's rranrt !s 1, m the heat at rap <br /> Standing level after well it. knumleds:e and bEIRI. , <br /> (11) WELL TESTS SR u <br /> Was well test I lr- I I A Si 11 re. b, .t)'eil llrh r� <br /> Type of test P n+ ' Z Naile IJ An lift r - I <br /> Depth r t �t 11an f tell — r- At end of fest ft 'r}{� '1QGFo pnnndl <br /> fOlschr" sJ -Itrr- h u. %krte tempentrsre <br /> Chemical a..I sus maJ 1 v 1 \ X It yr ov VRI147-15 $B -Was eleotno log mMr? 1 s (1 Nn If attach t e N�•. Late of th s relwr <br /> o <br /> ' DWR tee REV t.7 . IF ADDITIONAL S E E NSEC UTIVELY NUMBERED FORM z'E,= '711.11..o I T,L,, <br /> f <br /> i APR 201978 <br /> € ^` SAN JOAQUIN LOCAL <br /> HEALTH DISTRICT <br /> J <br />