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' 2 <br /> ORIGINAL STATE OF CALIFORNIA Do not fill a <br /> THE RESOURCES AGENCY <br /> with DWR DEPARTMENT OF WATER RESOURCES NO., 216103 <br /> of Intent No WATER WELL DRILLERS REPORT <br /> State Wen No / <br /> PV�Pen-rut No or Dat0e <br /> F' Other Well NOC <br /> ( I) OWNER N.me B (12) WELL LOG Total depth <br /> ft Depth of coniplctetl .ve11 __It <br />'Addres B Q X 17 2 8 From ft to ft Formation (Describe by oolor Lharacter sue or material) <br /> city n CA zip 95201 <br /> (2) LOCATION OF WELL (See tnbtructions) 30- 40 Bltjp_qreL-n , Dense Cla�L <br />'Counry S n Joaquin Owners Well Number- 1 0 #2 - nd Jens <br /> Nell address if different from above S 5 50- 60 B-1 u e q re e 1 a <br /> Tij%vn%hip 11 N Range Sectio 60- 135 B 1 u r e e n wZ sandn <br />'Distance from cities roads, railroads fences etc - 159 C o u S <br /> 159- 165 C1 a r e e n <br /> 165- 170Sand `. <br /> 170-_a(3) TYPE OF WORK <br /> New Well ❑ Deepening ❑ <br /> Reconstruction ❑ - B 7-4 <br />' Reconditioning ❑ <br /> Horizontal Well ❑ <br /> Destruction ® (Describe <br /> destruction materials4 <br /> procedures in Item I3r v - �. `�� l� <br />' (4) PROPOSED U < <br /> Domestic �-. C3, <br /> See Map Attached Imgation ❑ _ `�' <br /> Industnal 1��1� ❑ <br /> Tes 14Ve11 `��1 ❑ \ ` <br /> Stock \ ©4 \�J - •� \ <br /> WELL LOCATION SKETCH f �� Other ❑ <br /> (3) EQUIPMENT (6) GRAVEL PACK _ - <br /> Rotary Reverse ❑ Yes ❑ No ❑'> Size <br />'Cable Cl Air ❑ Dias titer of bore 6 1/8,. <br /> -� - <br /> Other Kj Bucket ❑ Packe4 <br /> (7) CASING INSTALLED ` (8) PERFORATION$- <br />'Steel ❑ Plastic ❑ Concrgfe,b,� Type of perfoz.2on-pr size'of screen - = <br /> From To Dia Cage- Front` `�To Slot` <br /> ft ft :n Wall ft `` ft stze, <br /> t \\`, <br /> \v \1 <br /> � � v <br />�(9) WELL SEAL 1I = <br /> Was surface sanitary seal provided' Yes K) No Q If yes to depth 4 5 h <br /> Were strata sealed a ainst pollutionit Yes C3 No C3 Interval_ ft <br /> Nfethod of se Cie m e n t G r O u t `York started 19 Completed <br />�(10) WATER LEVELS WELL DRILLT S STA HENT 4 'Z <br /> Depth of first water of known Thu well was dnI my ry ictton and this report u true to the best of m, <br /> Standmg level after well completion - ft knowledge a b i <br /> (11) WELL TESTS SIG`ED <br /> Was well test made° Yes No (� If yes, by whom? (We Drab))Type o0 test Pump Bailer C] Air ❑ NAME_. d l d m o n d e Drill 1 n g Inc- <br /> to water at start of tett fr_ At end of test_ ft y n (P6 firm, or corporation) (Typed or printed) <br /> rnia LN <br /> ge sal/nun after. Water ttmperattue Address 1 V I+ A (� <br /> I analysis made> Yes ❑ No [a If yes, by whom? City Palo C e d r 0 C A p„7 b 0 7 3 <br /> electric Ioi) wade' Yw Yo ❑ if yes attach copy to this report El I icense Nom 51 2 0 6 Date of this report--4- 13-89 - <br /> oWR fee (reV 7 lei IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />