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1 <br /> +� STATE OF CALIFORNIA `S <br /> QUADRUPLICATE THE RESOURCES AGENCY DO not fill in <br /> Use to comply With DEPARTMENT OF WATER RESOURCES <br /> local requirements WATER WELL DRILLERS REPORT No. 253000 <br /> Notice of.Intent No. State Well No. <br /> Local Permit No. or Date AFi-99I3 Other Well No. <br /> (1) OWNER: Name girhard nix (12) WELL LOG: Total depth_ft.Completed depth 260 ft. <br /> Address from ft. to ft. Formation(Describe by color,character,size or material) <br /> City MAnt PCA, CA ZIP _ <br /> 20 ;and <br /> (2) LOCATION OF WELL (See instructions): 20 - 25 Clay <br /> County San Joaquin Owner's Well Number I Sand <br /> Well address if different from above 31 — 73 Clay A Shale <br /> Township Range Section 73 <br /> — 79 Sand_ <br /> Distance from cities,roads,railroads,fences,etc. <br /> (3) TYPE OF WORK: — <br /> New Well XX Deepening ❑ — _ <br /> Reconstruction ❑ — ft <br /> Reconditioning ❑ 158 ^ f <br /> Sand <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) Vit <br /> (4) PROPOSED US _ <br /> Domestic 9A7— <br /> Irrigation .t <br /> Industrial ❑ _ --i\ <br /> Test,Well ❑ _ <br /> Munici ❑ O <br /> er _ <br /> WELL LOCATION SKETCH �) — <br /> (5) EQUIPMENT, CRA CK: — <br /> NJ <br /> Rotary L1Reverse No Si <br /> Cable ❑ Air ❑ et of bore Al 1A <br /> Otber ❑ Buck edom _ <br /> EALTH i <br /> (7) CASING INSPALLED: (8) PE TI — kiiiRMrrjsERVICES <br /> Steel Plastic ❑ Ty oI f 'on or size of — <br /> FromD' Gage or of — <br /> ft. f I Wall I. size _ <br /> i <br /> • — <br /> 155 Fin El <br /> (9) WELL SEAL: — <br /> Wassurfamsanitarysealprovided? Yes []r No ❑ If yes,to depth 2o ft. — <br /> Were&rats sealed against pollution? Yes ❑ No ❑ Interval ft. — <br /> Method ofscaling Work started 19 Completed 19 <br /> (10) WATER LEVELS: WELL DRILL R'S STATEMENT: <br /> Depth of first water,if known ft <br /> Standing levet after well completion 4Q ft This well was drilled under my jurisdiction and this report is Nue to the <br /> s g P best of my knowledge and 6efief. <br /> (11) WELL TESTS: Signed <br /> { Was well test made? Yes No ❑ Ryes,by whom? �y�p� (WellDiilT.rJ <br /> 1 Type oftest ,Pump (C' Rader ❑ lirmq s NAME <br /> �. Depth to wateral startoftest fY EE At end of[es[ ft. gqC arson, u r moon y o prin <br /> Discharge_gal/min after ATTA NED Watertemperature Address 362 PF16ANDALE AVE. <br /> I Chemical analysis made? Yes ❑ No !(ye;by whom? City 1400PSTO_�G.A ZIP 963F <br /> Irl Waselectric iog made Yes ❑ No If yes,attach ropy to this report License No. Date of this report iSO <br /> DWR IW(REV, 12-1361 IF KoDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM 86 96355 V V <br />