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QUADRUPLICATE <br /> Use to comply with STATE OF CALIFORNIA DD not fill In <br /> local requirements THE RESOURCES AGENCY <br /> DEPARTMENT OF WATERRESOURCES No. 22644 <br /> ti.a of Intent No._. WATER WELL DRILLERS REPORT state Well No. <br /> I,teal Permit No. or Dnte -.7-12Y Other Well No. <br /> r 1) OWNER: Name_ (12) WELL LOG: Total depth ft. Depth of r.enplenal welt ft. <br /> address 226 S• it ort way from R. to ft. Formatio (Describe by color, character, siize or material) <br /> al Mantecas Caal.if. zip0-;3 Top soil <br /> 2) LOCATION OF +WELL (see instructions): <br /> l9I Clay <br /> ' rrnty Sa.n .TMQnin Owner's Well Number _ <br /> ,fell address if diHere.t from above55-43 clay <br /> U.l"sfarenshcr1pT Annge O® <br /> Sectio <br /> 6 3—:71 Cgnd <br /> front cities, rands, railroads, fnces, tV.Hay! Rd 100t71-78 clay <br /> North of X eft1lin ast <br /> side <br /> �la3r <br /> (3) TYPE OF WORK: 100-425 clay <br /> New We11XI Deepening ❑ _ <br /> Reconatrvctinn ❑ <br /> 131-i1a In lay <br /> Reconditioning ❑ sarlA <br /> Horizontal Well ❑ B3 iie C1 ay <br /> (J <br /> Destruction ❑ (Describe <br /> destmction materials and <br /> procedures in It. 12) - <br /> Blue elay <br /> (4) PROPOSED USE: - <br /> Dnmcstio ❑ <br /> Irrigation �24,;2�8 Rine stand <br /> Industrial ❑ R1 1108 Clay <br /> Test Well ❑ <br /> Smek ❑ <br /> Municipal ❑ - d <br /> WELL LOCATION SKETCH I Other ❑ - <br /> (S) EQUIPMENT: (6) GRAVEL PACK: - <br /> Aotay ❑ Reverse z] Yes. No ❑ Si Ziraftelys _ <br /> Cable ❑ Air ❑ Diameter of bore N <br /> Other ❑ Bucket ❑ Packed from M 2a5 ft. - <br /> Ia (7) CASING INSTALLED: 181 PERFORATIONS:louvered <br /> f Steel W Plastic ❑ Concrete ❑ Type of perforation or sic of screen <br /> From To Dia. Gage or From To Slot <br /> ft. ft. in. Wall ft, ft. size - <br /> 4 - <br /> (9) WELL SEAL: <br /> \Vas sarfaee sanitary seat nnnSdedF Yes It No b It ves, to dept) R. - <br /> I Wrere strata sealed against nnllntion? Yes ❑ No ❑ Intenal _ft. - <br /> Method of scala.^ Work started lU Cut oActed 18 <br /> (10) WATER LEVELS: WELL DRILLER'S STATE. NT: <br /> Depth of first water, rt annw'r. - t. This .1 max 11,0M and.v mo mold......o r,d 'J", n u„r i row Io the best n/ mn <br /> Standing level after well c nnnleti-n-_ _f. knou;ledge mrd laerel- <br /> I lI) WELL TESTS Slcn¢o —Was well test ...ad.e 1If ves, by whr not <br /> Tvpe of t_t 1 I Hailer ❑ Air Ittt CI NAME� <br /> Depth t ++.ter .It art f t1t_32.Ot. At end nt tes H I e, r. a cu Hata t nm <br /> i <br /> n r <br /> 1> cf ame_ lklL cal min ntl•r-1�-hour> Wamr temperature Addrev__4500- - <br /> .7.rr'v clvv Ali- �� <br /> Chemical rsl so mad a Yes C: No r It y s by wh m. _ Cif.�sto. .3.3L.- - - -�'n9 50 <br /> - <br /> i W I t In, d Y ❑ N.Z if v ttt+h ism to this report I License Nn a]_-_.�T.�.rA��9 Uatr nt this rep, 02� cn ewo .r Osis <br /> DWR lac .REV 7.76 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> I <br /> I <br /> F <br /> j <br /> I <br /> ( <br />