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QUAVRUPLICATE STATE OF CALIFORNIA U DO HOE fill in <br /> Us*to comply with THE RESOURCES AGENCY V G �� 1l17f1 <br /> 1ocalrequitlmeMs DEPARTMENT OF WATER RESOURCES JJ JJ No. 083730 <br /> Notice of Intent No. 159319 WATER WELL DRILLERS R RTDAQUINs,1d0QeA�Nr. <br /> Local Permit No. or Date 79-634 HEALTH DIS�t6' Il No. <br /> (1) OWNER: <br /> k//��N//ao�me Gotta P!o • IDC (12) WELL LOG: Total depth 1M. Depth of completed wen lok <br /> 20200 <br /> es <br /> Addrs N, Thomton Road From ft. to H. oeatlan (Describe by color, character, size or material) <br /> C;ty Lodi, Calif, -Zip_ <br /> (2) LO�TIOj02F1IILj (See instructions): <br /> County a9 <br /> Owrcrs Well Number <br /> Well address if diff6¢)eat form above aq <br /> 11 1 1 of <br /> Township 1 x Range� 9�ectin <br /> 657 5 <br /> Distance from cities, mads,mllroads, fences,ere_ J`•/V • _ <br /> Aa- <br /> .. .. _...-. . ._ (3) TYPE OF WORK: <br /> ' <br /> New Well A Deepening ❑ <br /> - Reconstruction ❑ - <br /> Reconditioning ❑ - V. <br /> Horizontal Well ❑ - `! <br /> Destruction ❑ (Describe <br /> destruction materials CS LJQ COV(ir was J.II$tdl @d OA <br /> ` <br /> procedures be Item Y e 8 m not S-W r7 er. • <br /> x poo b e or <br /> 9 <br /> (4) PROPOSED 8any $ t`t'}<"33l$ OI' T�"i28V rin� O t se& <br /> Domestic OS C , —� <br /> . lrrigxtion� — � <br /> -. Industrial O ❑ � <br /> Well ❑ — 7� <br /> Stre <br /> Munici — <br /> WELL LOCATION SKETCH Other <br /> (5) EQUIPMENT: (6) GRA PACK: <br /> Rotap IT Reverse ❑ IF No Sia — <br /> Cable ❑ Air ❑ er of bore — <br /> Other ❑ Bucket ❑ rum = <br /> (7) CASING INSTALLED (6) PERF <br /> Steel El Plastic G Type of Pe nor ze of scree — <br /> From T Dia. G r F To — <br /> ft. f in. Wall ft. S; _ <br /> (9) WELL SEAL: 2 p - <br /> Was surface sankruy seal provided? Yes 13L No ❑ if yes, to depth A H. <br /> Were strata sealed against pollution? o ( Interval N, - <br /> Method of seanv f2p 4_1 <br /> Work started 9 Completed 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known This well was drilled ander 1 <br /> mp {urisdict ea led this report is true to the besr of mp <br /> Standing level atter well completion H. knowledge and be/ir/. 1. / <br /> (11) WELL TESTS: SIGNED <br /> 4:'1' <br /> Was well test made? Yes ❑ No (F If yes, by whom? ( Ven filler) <br /> Y <br /> Typeof test Pump El Barer ❑ Air lift ��❑ NAME PWal ri,'ling; Inc, <br /> Depth to water at start of test N. At end of test h 31(��, fin, n cff pmu�ti�r�sLTvaed�r�rylled) <br /> Discharge gal/min after hours Water temperature Address Wii tl0 I�ViV <br /> Chemical analysis made? Yes ❑ No ❑ If yes, by whom? Crry Calif <br /> • Z' <br /> Was electric log made? Yes ❑ No ❑ If yes, attach copy to this report License No. Data of this report <br /> DWR 188 (REV.7.76) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />