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QUADRUPLICATE STATE OF CALIFORNIA Do not fill in <br /> Use to comply with <br /> local requirements THE RESOURCES AGENCY ����L <br /> No. ^ <br /> DEPARTMENT OF WATER RESOURCES <br /> N,ti,a of Intent No. WATER WELL DRILLERS REPORT state Well No. <br /> Goch)Permit No. or Dnte - Other Well No. <br /> (1) OWNER: Name Roos Bros* (12) WELL LOG: Total depth 2�k, Depth of completed wen o k. <br /> qq <br /> Address 2 522 5• AirPort WarI from (t. to k. FnrmaHmn (Dcscribe(Describeby rnloq character, size on materiel) <br /> 1Aanteca, 9*12 , ,;p O soil <br /> r:io. e, <br /> k (2) L�An wt OgFa4�ELL (Seeinstruetions): C e . <br /> am <br /> (:aunty Z uiu Oamei s Well Number C' <br /> Well ades <br /> drs if diifYirent from above O 1 `end <br /> 1\ovmh41 +, Range E Scale �.'20 Clay <br /> Distance from cities, cVadraijia dsp fencea ete �� Corner 67 <br /> n,4 <br /> .Ye• {1 ['}{cam_- _ <br /> l <br /> 69-17Nand <br /> (3) TYPEOFWORK: <br /> 4 New Well4 Deepening ❑ C1 aY <br /> llc nomtructinn ❑ Land <br /> I <br /> Recnnditinning ❑ <br /> Horizontal Well ❑ -'-and <br /> Destruction ❑ (De scribe. 130,135 U <br /> destruction materials and q <br /> irmced. in Item 12) r O nd <br /> (4) PROPOSED USE: <br /> 140-150 CI a 7- <br /> Domc:tk �t❑ <br /> Irrigation A <br /> Industrial ❑ �C <br /> Test Well ❑ <br /> Stock ❑ <br /> Municipal ❑ a i..._. ' <br />( <br /> 1 WELL LOCATION SKETCH Other ❑ <br /> I (5) EQUIPMENT: (R) GRAVEL PACK: p���t� <br /> Rotary ❑ lie cm, A YesA No ❑ Si-e _^�"� <br /> Cable ❑ Air ElDiameter of bore iL}I '^ 1A up, 111JE clay <br /> Other ❑ Bucket E! Pocked from I.—U-0 �t <br /> (7) CASING INSTALLED: (S) PERFORATIONS: louvered <br /> Steel] Plastic ❑ Concrete ❑ Type of perforation or size of screen - <br /> From To Dia. Cage or From To Slot - <br /> ft. ft. in. Wall ft. ft. size - <br /> (k 0lei k 90i - <br /> [ (9) WELL SEAL: <br /> Was surface sanimry seal provided' Yes No ❑ If yes, to depth I. - <br /> Were strata sealed against Pollution? Yes ❑ No F7) Interval R - <br /> Method of sealirr Work started 19-ZM Completed-19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth of first water, it knussa k. This ..It Ices drilled under nm m,isdictloa ,oul thi...r,t.. 0 tore to the hest of mp <br /> Standine level after well coomletio k km,ruledga and beurl. <br /> (11) WELL TESTS: S1CNEll <br /> Was well test made? Yes n No l;if vee, by who., t bl'rii Driller I <br /> Type of test Pump F Boiler ❑ Afr, uk❑ N n NIr Aanni nor. Rma_ titut Ir1P___ <br /> Depth to water at M.rt of test__ b. At end of test ft �� (P s hmr, ..r oorpn+abun (Typed nr f7T.med) <br /> Discharge _col m after_. hn,+. R' t temperanu'e Add •u3�-t.�5 71 1. ndnin Avg, _ <br /> en.to_ Calif., <br /> Lp_- 7ir�s <br /> Chemical mvlvsis mad les i i It s b whom?— t''ty --bIod ' <br /> Was electrictoe made? 1 ❑ i Ii to thk report L 1 290813 1l t f fl port <br /> DWR tee inev. n-ve. IF ADDITI&AL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <ea+c-ase,.,6,..ee..D tDOSP <br /> 1 <br />