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Cttatowr obtained permit <br /> I <br /> I <br /> QUADRUPLICATE STATE OF CALIFORNIA Do not fill in <br /> Use to comply with THE RESOURCES AGENCY No. 064854 <br /> local requirements DEPARTMENT OF WATER RESOURCES <br /> Notice of Intent No. WATER WELL DRILLERS REPORT State well No <br /> Lural Permit No. or Date Other Well NO._ <br /> (1) OWNER: a <br /> Num{e p�� x'11 t S (12) WELL LOG: Total depth it Depth of completed well_125 R. <br /> Address 2120 Wilcox Rd. from ft. to f. Formation (Describe by rnlor, charneter, sre at material) <br /> City Stockton• Calif. 0 6 Send <br /> - <br /> (2) IRQBCnATJQN OE WELL (See instrnet ons): - Ci <br /> County o vV 1.1•1I•1 o.9e"s li"Nmnber 7 — 7 g� <br /> gm- <br /> Well address d diffenrqrntt from <br /> y�pbb}Tu��v • h8h <br /> TownhiPn^_ C��7iange Sectio <br /> Distance fmm cities, roads, railroads,fences,etc. <br /> i (3) TYPE OF WORK: <br /> Neva Well X Deepening ❑ <br /> Reconstruction ❑ — <br /> NIX <br /> Reennditioning ❑ — <br /> Horizontal Well ❑ — <br /> Destruction ❑ (Describe — <br /> destmetion materials <br /> procedures in Item — <br /> (4) PROPOSED - <br /> Domestic P ♦ — it <br /> Irrigation O — <br /> Industrial\ ❑ <br /> Well J ❑ <br /> Slue z> <br /> Muni <br /> WELL LOCATION SKETCH Other ❑ — <br /> (5) EQUIPMENT: (8) GAA PACK: <br /> Rotary CK Reverse ❑ No St. — <br /> Cable ❑ Air ❑ er of bore ~ — <br /> Other ❑ Burket ❑ m — <br /> (7) CASING INSTALLED (8) PERFOAA S: = <br /> Steel ❑ Plastir� C c t Type of Pe nor ze of scree From Tr Dia. G r F To <br /> ft. f in. Wall f . ft s+ - <br /> (9) WELL SEAL: Qp(��� - <br /> Was surface sanitary seal provided? Yes (K No F7 If yes, to depth�ft. <br /> Were stoma sealed against yollution? Y'es ❑ No ❑ Interval ft. — <br /> Method of sesdm Work started 19_ Completed-2:7--&7=0 9 <br /> (10) WATER LEVELS: - WELL DRILLER'S STATEMENT: <br /> Depth of first water, if know ft. This well was drilled under my jurisdiction and this report is true to the bear of my <br /> Standing level after well completiu ft. knowledge and belie/. <br /> (11) WELL TESTS: SIGNED- �.�_ ��--ss pre,- Co., •r Bkkpr. <br /> W'as well test made? Yes ❑ No ❑ B yes, by whom? Calwater Lr rj 7 i rIQ W nc. <br /> Tree of team Pump ❑ sailer ❑ Air lift ❑ NAME ��V � <br /> Depth to water at start of test ft. At end of test N .S,CF,�nop,:.u,ryf upZvav,n) (Typed or Printed) <br /> Discharge oal/mm after hours Water tempemtare Address }VlJ J 1111LV+ <br /> Chemical analysis made? Yea ❑ No ❑ If yes, by who.?— Ci[y oc • • Zi <br /> Was electric lag made? Yes ❑ No ❑ If yes, attach copy to this report License No. Date of this report F3—N525 W/ 7 <br /> DWR lea (nEV. 7.)6) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I <br />