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t+ <br /> 'RIGINAL STATE OF CALIFORNIA Do not fiII In <br /> THE RESOURCES AGENCY <br /> ' 16 <br /> I <br /> le with nWR DEPARTMENT OF WATER RESOURCES No. 129428 <br /> of Intent No. 160902 WATER WELL DRILLERS !REPORT State Well No.o2Nd7E31 R03i <br /> Permit No. or Date -,-r,)65 � <br /> 1 'O i ) f'l Other Well No�N <br /> iS J <br /> 1) OWNER: Name a Whee 1 Mob' le Home Fk (12) WELL LOG: Total depth-1-90 ft. Depth of completed we3 3t^9Q Et. <br /> tti <br /> Addm,s 390` E. F=emont from Et. to 11 ft. Formation (Describe by rnlor, character, size �r material) <br /> , Stockton, C?17` . _ p9520 - il 4PAdobe <br /> tLCATI E Clay <br /> ( . (See instnictions): II an oaguin 3 —anOwner's Well Number <br /> `Fell address if different from above 38- ;1 3 Clay 'and sand layers <br /> +,nvnship Aanste SectioIL <br /> - San �) <br /> ia:fnee/from:i*r�[ies, nyads, railroads, fences, etc. <br /> agile a ress _ ay <br /> 01 No. -F road <br /> (3) TYPE OF WORK: <br /> +, d !� New Well [} Deepening ❑ E <br /> ReC9n5trlletiOn ❑ —li <br /> Ulay <br /> Reconditioning ❑ fn- <br /> [P Horizontal Well ❑ 1 <br /> Destruction C] layers- <br /> (Describe �� - <br /> destruction materials axitj <br /> procedures in Item 12 <br /> (4) PROPOSED Iu$E> <br /> Domestic , <br /> Irrigation <br /> industrial ❑ -_ -" <br /> Test Well ❑ A��.proper:_welcover was installed <br /> 5%eZ Stock" on zs. a, an -- am no <br /> " es onsi'D• ' or an altering or <br /> //' Municipal` ❑, Y g <br /> •i <br /> WELL LOCATION SKETCH Other ❑ - _ 16nea QTS casing. <br /> S) EQUUMENT: (6) GRAiVEL•PACY: <br /> 1 Rotary IN Reverse ❑ Yes No ❑ Size e - <br /> Cableof bore <br /> Air �. .1'715. <br /> ❑ ❑ Dianiater <br /> pa <br /> Ither ❑ Bucket ❑ cked from tn'- 1 9''1 k- - - <br /> CASING INSTALLED:,`~ ($) PERrQFY - <br /> r '`. <br /> Steel ❑ Plastic 5 Cdac'rete 0, Type of per£giailun or size of screen.'7' <br /> i <br /> From To Dia. Gagcor From. Li To <br /> ft. ft in. Wall f. -' ft. / .,\r sizes - <br /> 0 15,0 t Xti <br /> (9) WELL SEAL: - <br /> '-Pas surface sanitary seal provided? Yes X No ;❑' If yes, to depth ft. - <br /> L:- <br /> strata sealed against pollution? Yes {_j No Interval tt. -;o <br /> hrd of sealing Work starte 4 1 Complet 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT, <br /> radTh7epth of first water, if know Et. p <br /> is well wa, rer my Jrisdictinn nd i repo is eta the herr o/ my <br /> ,tanding level after well completion ft kru�uaedge.and y <br /> II) WELL TESTS: <br /> Was well test made? Yes ❑ No If ves, by whom? 'p (1 e Drilled <br /> Type of test Yump ❑ Bailer ❑ Air lift ❑ Paner6 Well Drilling;,3nc . <br /> NA.l9E <br /> )epth to water at start of test ft. At end of test ft 6 (person, fine, ur copoon <br /> rrati ) (Typed or primo n _ <br /> ischarge gal!min after h_uurs Water temperature Address 140 .'�E Lo n <br /> � 763 <br /> .+I analysis made? Yes ❑ No ❑ If yes, by whom? Road- <br /> city .Oakdale, Calif. -- _- ._Zi p <br /> Lefectric Ing made? Yes ❑ Na [] [f yes, oottach cop.• to Ibis retx+rt License Nn. i 3 3 3114 nate of this repo � $ <br /> WR lata {REV. 7.76) IF ADDITIONAL SPACE 15 NEEDED. USE NEXT CONSECUTIVELY NUMEEREDFOiRM <br /> L <br />