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ORIGINAL STATE OF CALIFORNIA Do not rill in <br /> THE RESOURCES AGENCY <br /> eQfe with DWI. DEPARTMENT OF WATER RESOURCES No, 197578 <br /> Of Intent No. WATER WELL DRILLERS REPORT State Well No. <br /> ..,?emit No. or Date v V 0 Other Well No O?yQ:; 2 <br /> ,..1} OWNER: Nad;eff Davidson (12) WELL LOG: Total depth-=ft. Depth of completed well 22-ft. <br /> Add,,,,,- 441 Lexington from ft. to ft. Formation (Describe by color, character, size or material) <br /> ty Stockton Calif. —zip-9,5204 - 99 <br /> j.?) JOCATION QF WELL (See instructions) <br /> an oaouin -1 - <br /> Coun Owner's Well Number G �} <br /> `bell address if different from above 2 d • b 02 Sand <br /> )wnship Tracy Range—Section 82 — 1o8 Clay <br /> y <br /> Distance from cities, roads,railroads,fences, etc, 1C — 117 Sand & ravel <br /> 202 Clay <br /> (3) TYPEOFOF WORK: - <br /> New Well IN Deepening ❑ — <br /> Reconstruction ❑ — <br /> Reconditioning <br /> Horizontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and — <br /> procedures in Item 12) <br /> (4) PROPOSED USE: <br /> Domestic <br /> �r Irrigation ❑ _ <br /> Industrial ❑ <br /> Test Well ❑ — <br /> Stock ❑ <br /> Municipal <br /> WELL LOCATION SKETCH Other ❑ <br /> moi) EQUIPMENT: (6) GRAVEL PACK: — <br /> Rotary JAI Reverse ❑ Yea X No ❑ si — <br /> �able ED Air ❑ Diameter of boors 11 <br /> ther ❑ Bucket Cl Packed from G' to 12 5 — <br /> ar`} CASING INSTALLED: (8) PERFORATIONS: — <br /> Steel ❑ Plastic Concrete Cl Type of perforation or size of screen From To Dia. Gage or From To Slot - <br /> 4 . ft. ft, in. I Wall ft ft. size - <br /> C 125 h - <br /> (9) WELL SEAL: <br /> —'as surface sanitary seal provided? Yes)] No ❑ If yes, to depth �t. — <br /> rere strata seated ' <br /> nit llution? Yes ❑ No ❑ l ft <br /> Interva . — <br /> "ethod of sea' Ten'onite Work started 19 Complet 19 <br /> (10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> epth of first water, if known This well: was drilled under my jurisdiction and thi report is true to the best o/ my <br /> tending level after well completion g, knowledge belie). 1 <br /> `11) WELL TESTS: SIGNED kA=2 z <br /> Was well test made? Yes 0 No ❑ If yes, by whom? (Won Driller) <br /> ype of test Pump [] Bailer ❑ Air lift ❑ .NAM <br /> Depth to water at start of test ft, At end of test ft (Person, firm,or corporation) ('typed or p tat ) <br /> 'T' urge Qat/mia after hours Water temperature Address 1 � n�---- <br /> AD <br /> cal analysis made? Yes ❑ No ❑ If yes, by whom? CityTlirInnk, Calif- �--�1� <br /> electric log made? Yes ❑ No ❑ If yes, attach copy to this report License No ate of this report 6 <br /> bwWR lata (REV.7.7e) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> am <br />