Laserfiche WebLink
him <br /> QUADRUPLICATE STATE OF CALI U11ADo not fill in <br /> Use to comply with r`N l.,5 1979 <br /> THE RESOURCES AGEN <br /> local requlremel,;ts7 <br /> DEPARTMENT OF WATER RESOURCF�S No. 21 1 <br /> 152168 .�,-� LOCAL <br /> Notice of Intent No. WATER WELL DRILL � STRICT state Well No. <br /> Local Permit No. or Date -+ Other Well No. <br /> (1) OWNER: Name john Van de Pol (12) WELL LOG: Total depth_160 ft. Depth of completed -elL left. <br /> Address 16996SeXton Road from ft. to ft. Form 'on (Describe by color, character, size or material) <br /> city EScalon. Calif Zip 95320 - <br /> (2) LO AI%$Qff LL (See instructions): 24 <br /> Owner's Well NumbeCount _ <br /> 00 <br /> Well address ififfegnt from above 9 E 88 10 14 11,1��vel <br /> - <br /> Township Rang -1 nil - <br /> fto D't fro ities r ds railroads,fences,etc. qQ ff <br /> { (3) TYPEOFWORK: Ile <br /> i New Well Q' Deepening ❑ <br /> y Reconstruction ❑ - <br /> j Reconditioning ❑ - <br /> `' Horizontal Well ❑ - <br /> i- <br /> w ",f y E t Destruction ❑ (Describe <br /> destruction materials <br /> procedures in Item <br /> f _ (4) PROPOSED p ASF@ G p� t�S 23S Hled <br /> Domestic a no TeSpO.n iv e <br /> 1-umoylLiK UL- <br /> tMle <br /> . l Irrigation ❑ <br /> {--^--••-^-- -- •-'`' Industrial ❑ <br /> _. -.-._. <br /> Ts Well ❑ - <br /> ~i Stoc icip - <br /> Mun - <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: (6) GRAV ACK: - <br /> � Rotary ❑ Reverse El No Siz <br /> t <br /> Cable ❑ Air ❑ er of bore - <br /> Other ❑ Bucket ❑ c rom t - <br /> k" (7) CASING INSTALLED: (8) PERF - <br /> Steel C] Plastic IS Co e Type of pe a or a of scree - <br /> From To Dia. Ga r F To <br /> ft. ft i Wall ft. ft. s - <br /> C <br /> bw (9) WELL SEAL: -0 <br /> Was surface sanitary seal provided? Yes ElNo El If <br /> yes, to depth ft. - <br /> Were strata sealed against pollution? Yes F1 No ❑- Interval It. - <br /> Method of sealingacme b Work started 19 Completed - 19 <br /> 1' (10) WATER LEVELS: WELL DRILLER'S STATEMENT: __. <br /> Depth of first water, if know ft. This well was drilled.under my jurisdiction an 2h' report fs true to the best of nib <br /> Standing level after well completio ft, knowledge and belief.- - <br /> (11) WELL TESTS: yy 1 SIGNEn a, <br /> Was well test made? Yes ❑ No:6 If yes, by whom? panero elf'76 11iingj; Inc <br /> Type of test Pump ❑ Bailer E] Air lift El NAME <br /> •� <br /> Depth to water at start of test ft. At end of test ft P on, co orad ed) <br /> Address 3l4'5 � � <br /> Discharge------gal/nun after hours Water temperature Vik - , - <br /> Chemical analysis made? Yes El No ❑ If yes, by whom? <br /> City_ Z� <br /> Waselectric log made? Yes ❑ No ElIf yes, attach copy to this report License No. Date of this report <br /> DWR 11111 1REV.7.76) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />