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I <br /> QUADRUPLICATE STATE OF CALIFORNIA DO not fill III <br /> Use to comply with h <br /> local requirements THE RESOURCES AGENCY No. 129435 <br /> X60"6 DEPARTMENT OF WATER RESOURCES <br /> Notice of Intent No. - WATER WELL DRILLERS REPORT <br /> --7#-73k-- State Well No. , <br /> Local Permit No,or Date <br /> Other Well Na_ <br /> I <br /> Richard ee" 2 <br /> (1) OWNER:- �' (12) WELL LOG: Total depth ft. Depth of completed v IL_ft. <br /> Address from ft to h. nrmn 'on (DeAl by color, chameter, size or material) <br /> City ucalong cal.11. Zip <br /> (2) LO("OMWLL (See instructions): <br /> Cou. Owner's Well Ntunber <br /> Well address if diRer�t from above <br /> J <br /> 88 Swid <br /> Townsbj LL Renge_���.�eclin _ - <br /> Distance form cities, roads, railorad108 Glay <br /> s,fences •�QYeS� - <br /> 112 144 Clay <br /> 144- 156 Sand <br /> . _ <br /> (3) TYPE OF WORK: 156 <br /> -r—" — --"-"-- New Well 172 C3 gy <br /> Deepening ❑ 172- <br /> IRS <br /> 080 rl ay <br /> Recnnstraction ❑ <br /> Reconditioning ❑ - <br /> Dodumtal Wen ❑ <br /> J (( Destruction ❑ (Dose e - <br /> ( destruction materials <br /> 1'\ procedures in Item I _ <br /> j (4) PROPOSED <br /> Domestic ❑ - <br /> / Irrigation - <br /> _ ' Industrial ❑ Proper "11 caver wan installed <br /> �_... <br /> not reePenelb <br /> T(Si Well ❑ - ' <br /> 1 Stock ❑ 't <br /> ' Muvfcipal. ❑ <br /> WELL LOCATION SKE'rcil Other ❑ - <br /> (5) EQUIPMENT: (6) GRAVEL;YCK: - <br /> Rotary ❑ Reven, ❑ �,, x1 <br /> 3,❑ No Size - <br /> Cable PF Air ❑ - r of bore_ - <br /> Other ❑ Bucket ❑ -{mm to ft - <br /> (7) CASING INSTALLED: (S)'PERFO{RATIONS: - <br /> Steel Plasdc ❑ CI a Type of per,'Okop or'slze of screen - <br /> FnaB To Dia. Ga r Froaa To Slot = <br /> Wall ft. ft size. <br /> (9) WELL SEAL: <br /> Was surface sanitary seal provided? Yea ❑ No X If yes, to depth k. - <br /> Were strata sealed against pollution? Yes ElNo 1F Interval k. <br /> Method of sea' Work started 19 Completed 19 <br /> (10) WATER LEVELS: � WELL DRILLER'S STATEMENT: <br /> Depth of first valor, if knowc <br /> n W k. This well was drilled under ml/ jurisdiction and this reparl 'to the best of m9 <br /> Standing level after well completion k, knowledge and belief. <br /> (11) WELL TESTS: SIGNED <br /> Was wen test made? Yes ❑ No IX If yes, by whom? `t�rrr �' <br /> Type of test Pump ❑ Bailer El Air lift E) er <br /> NAME p" G Meu1ng1 Inc. <br /> Depth to water at start of test ft. At end of test <br /> Discharge gal/min after boon Water tempemlure Address �� •� Lyy�tr raj t>ai yly� ) <br /> e� .1.ii AValii <br /> Chemical analysis made? 1f s [I No El U yes, by C <br /> ;ZiA2 -12162 <br /> X 46 <br /> Was elaetdc log made? !Fes ❑ No ❑ If res, a e of t Ix o Lies 'o. Date of this repo <br /> DWR Ica (REV.7.7.1 IF ADDITIONAL SP W IS NEEDED. USE NEX SECUTIVELY NUMBERED FORM <br /> JUN 2 1978 <br /> SAN JOAQUIN LOCAL <br />