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i <br /> QUADRUPLICATE STATE OF CALIFORNIA Ito not fill in <br /> Use to comply With THE RESdU RCES AGENCY n' r�p <br /> Eo�calrequirements DEPARTMENT OF WATER RESOURCES No. 142836 <br /> Notice of Intent No. rao62WATER WELL DRILLERS REPORT Mate Well No. <br /> 0101504 <br /> i <br /> local Permit No. or Datc Other Well No.� �/. <br /> (1) OWNER. " <br /> W EA: o W'�' dam D6 Jong9 Jr. (12) WELL LOG; Total depth S'(t, Depth of completed well ft. <br /> 13776 W Pon Ed. <br /> Ripon� <br /> Address Lmnr ft. to ft. Formation (Describe by color, character, size or material) <br /> —Zip City R - <br /> 17 <br /> d <br /> (2) L JTTQgaQ&AELL (See instructions): - �Y ' <br /> County y ��ii —Owner's Well Number Li$ <br /> Well address if different from above aF <br /> Township Range 'ec�yj <br /> 4V 4�7f sand <br /> Clay <br /> tlbf-1 a t[7adbrlrgotl• f s`e8 H _ <br /> P 1 II�� �1 iOW 0ana <br /> (3) TYPOF WORK: - ey <br /> I New "N Deepening ❑ 118 - 125 Sand <br /> Reconstruction ❑ 1 xz - Ig clay <br /> Recanditioning [] - Saw <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe - I <br /> destruction materials and <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: - <br /> Domestic - <br /> i <br /> Irrigation ❑ - - <br /> Industrial ❑ - <br /> Test Well [] - <br /> Stock ❑ <br /> Municipal ❑ -WELL LOCATION SKETCH Other ❑ <br /> (5) EQUIPMENT: (6) GRAVEL PACK: bird sey - <br /> Rotary lb Reverse ❑ Yes 4 No [JSia. {7 <br /> ir <br /> Cable ❑ Air ❑ Diameter of ho - P <br /> Other ❑ Bucket ❑ Packed from to It. - <br /> (71 CASING INSTALLED: (8) PERFORATIONS: - <br /> Steel ❑ Ylasticx Concrete ❑ Type of perforation or size of screen - <br /> Frotn To Dia. Gage or From To Slot <br /> ft. ft i Wall ft. ft. size - <br /> (9) WELL SEAL: �y� <br /> Was surface sanitary seal provided? Yes No ❑ If yes, to depths-ft. <br /> Were strata sealed :�gig�td ,Wes ❑ No ❑ Interval ft.. - <br /> Method of sealing Dom$ Work started 19 78 Cotup)et. 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, if known This well was drilled ruler my jurisdiction and this report is true to the best of my <br /> Standing level after well completion ft. knowledge and,Wief. <br /> (11) WELL TESTS: SIGNED- f <br /> Was well test made? Yes ❑ No; If yes, by wham? (Well p�yrill �t <br /> Type of test Yump ❑ Bailer ❑ Air ]iEt ❑ NAR4E P.ni� �rP? �rQs. 1/Z'�il 1�o.q Ine f <br /> Depth to water at start of test ft. At end of test ft su fi r• ur c rp tirm) (Ty ed or printed) <br /> Discharge nal/min after hours Water temperature Address 3$Y Pei1a inch a T4 A Ve• <br /> Modesto Ca. 95352 <br /> Chemical analysis made? Yes ❑ No If yes, by wlxa»sx? City - <br /> Was electric log made? Yes ❑ No If yes, attach copy to this report License No. 2900 13 D.,of this report <br /> 10-1 2-7b <br /> DWR 188 (REV.7.76) IF ADDITIONAL_ SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />