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{ <br /> :Y <br /> _ - STATE OF CALFFOPMIA UD not f fit in <br /> THE FESOURCES AGENCY <br /> ORIGINAL DEPARTMENT OF WATER RESOURCES No 290676 <br /> x . <br /> n <br /> File with DWR WATER WELL DRILLERS REPORT IV <br /> State Well No. <br /> Notice of intent No, Otn•r Well <br /> 88-3126 <br /> Local Permit No.or Date ft.Com lrted depth�—fG r <br /> (1) Ow Name oe Rose <br /> (12) WELL LOG: Tsttal depth inn P <br /> - 25ra16 $, B3iltd Rd. from Ft. to ft. Formation{Describe by molar,character,silt[or tna ��tall a <br /> =: AddremF Tracy Ca. ZIP 95376 <br /> City <br /> ' f WELL(See instructions):. <br /> (2) LOCATION OF j <br /> v S3rg' LT01 in Owner's Well Number - �=I <br /> County. r, 7 V n <br /> Well oddreYs if different from above <br /> acVRange�---Sectfor. <br /> TvwnshEp._ ` — - S <br /> Distance from cities roads railroads fences etc. <br /> _ tt <br /> (3) TYPE OF WORK: <br /> New Well XX Deepening ❑ <br /> a rr .y Reconstruction ❑ <br /> } Recvriditioning s <br /> ❑ " . <br /> Horizontal Well Q <br /> Destruction ❑ (Describe n <br /> +t V destruction materials and pro- , <br /> cedures in Item 12) <br /> (4) PROPOSED US <br /> r z.N; <br /> Domestic priVt <br /> �I r Irrigation a' <br /> industrial ❑ i <br /> Test Well Q ❑ e <br /> MunicE l ❑ - Y �y5 5 <br /> be <br /> Q er <br /> WELL LOCATION SKETCH •..n ,x,.Y "'" tI <br /> r <br /> f f51 EQUIPMENT.' S} CRAY CY r <br /> No 12 - - - • <br /> Rotary ® Rewene ❑ i y_ <br /> J: CJhk'-,❑ Alr� ❑ Nr fbore <br /> a aM Other ❑ Bock c ran «� � <br /> iNSTALLEa- - _ (8) PER TI - <br /> )�5: Ty of fo 'an or size of - L ; <br /> `Steel.❑ plutir (� <br /> T t T u ws Mi. <br /> From .T i Gage or,. c � <br /> r Etr?F f f Walt L size <br /> wy. <br /> w' Y:. <br /> 10 <br /> 160 85 <br /> h <br /> WELL'SEAL _ r R <br /> (g) . Ft <br /> t� Wu surface ranitary sat provided? Yes M No ❑ [f yes,to depth r <br /> ❑. No❑ tntcrval R <br /> were stmtasetlediiilliklpollutian? Yea Ig Completed — !9 +� <br /> ' <br /> Method of sealing Work started -- r <br /> WATER:LEVELS: WELL DRILLS•R'S STATEMENT: 's <br /> .(10):- <br /> Depth of[test watei,if known ft 7hta turll u �dreffed antler m furtadletlon and this repot! is true to llsC s <br /> -Staxdin;level after well cwnptetiaai Ft Urst o/rn k vlalydge and fxf[r r <br /> (11) WELL TESTS: .' Signed <br /> yrs, wham? •' (W'zll Drt ) s. <br /> Was well tdtmade,? - Yes ❑ No❑ - If AirEift ❑ NAME Ct'tlwater Drilli _ ALI <br /> t t _� Type of teal:'�. .. Pump❑ - Railer _tgezraR i1r11L ar Ca[prlAliOM1.iTyY"'a PNM ) <br /> ft. - At etd of test it 1C1.L <br /> r' tkpth to water at start of test Address,300 S. r4Y - <br /> houn water temperature zip �-M--- <br /> Dtfchetgr -' gal/minaFlrr city aS�s +—� -� �p , <br /> d Chemleol analysis made? '_Yea Cl-' No❑ if vec by wham? Date of this re rt.�l1-AL7- ti-- <br /> z No❑ EF vet attach Iothts rc Licrrtw No -- ., <br /> WuelMrla made-` Yea ❑ M rias , <br /> IR ADOITIONAL SPACE t8 NEEDED. USE NrtiT CONSECUTWaLY NU MBl RL17 FORM <br /> y Y <br /> 0Wpj log 124M <br /> r� isth snn ss � � t <br /> �',a:;eh.�;.-.r... ' <br /> '` -ry * i f '�� S•"`sYj � .Lti:� -,x:t. � "a v'- -�# t �#... ^� ,,3"`<,#:.,_'' .,l <br />