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<br /> QUADRUPLICATE SfATBOFCALIFORNIA Do not fill in.• ,
<br /> Usr�af:omplywith THE RESOURCES AGENCY �. No. 219454
<br /> J&al requirements DEPARTMENT OF WATER RESO RCES
<br /> N••ta<,rf Intern.•,.___ NATER NVELL DRILLERS R.6 0RTr;
<br /> other\Cult Nu. _
<br /> 1 li•t-nl 1'ennit No.ur hate-_
<br /> Total depth--t0t.Drl,th of eompletetl-ell9 5ft,
<br /> i I) OWN Ell: N.tr„r--- — -- —�O h:1 V a 1 a d a c (12) WELL LOG:
<br /> rn`n, ft. I., ft Fonnation (Describe by ,.le)r, rharnete size or material)
<br /> 1530 Frank 1 i n Ave-.---.- -,
<br /> Tracy, ,i,,._ 95I r - 5 _ ion Saf I
<br /> (:it -- Ca --- - 15 C 1 a v I
<br /> (?) LOC &TI N OF «'ELL 'Sm-instnictions): ��� - 3'J Sand
<br /> n_�o a qu i n Owner's \\'rn Ynrr,hrr-----'----- d a CI a
<br /> 20700 S. Laurel 30 - p
<br /> \fell addres,if different from A.,rr_ _ -------------- Qn Sand
<br /> . Tracy Hanue Sect+„n_-- ��) - V J U
<br /> 7'•,wn>bip- - t.o rt h 9 0 u e a '
<br /> Distance fr•,m cities,roads, mle-Is,fen[.•s,etc._'�-_ �- -- �
<br /> Arbcr ltd. eas s1 e -
<br /> - I
<br /> (3) TYPE OF WORK:
<br /> New• Well r)rrle,nnc ❑ -
<br /> ltaronslrnction ❑ - .1
<br /> Hcamditioninq ❑
<br /> I
<br /> Zhorizontal Well ❑
<br /> Drstnrctiun ❑ (Describe -
<br /> destruction materials and _
<br /> pn,ardures in Item 1.3) -
<br /> (4) PROPOSED USE:
<br /> D,nnntic Cr -
<br /> Irrittatinn ❑ -
<br /> Industrial ❑ -
<br /> ' EE
<br /> rest \Cell ❑
<br /> Str,ak C -
<br /> Munkipal
<br /> WELL LOCATION SKETCH Other ❑ - -
<br /> 15) EQUIPMENT: 18) GRAVEL PACK: Sand '
<br /> Rolan `Ya
<br /> ry Heverse ❑ Yes:), Vo❑ SizrM i I
<br /> + 1
<br /> Cahle ❑ Air ❑ Diameter of tx,rr 1 1 -
<br /> L�•' Cit
<br /> Ottrrr ❑ Auakrt Parkrd from— `�G _tis t.
<br /> I:) CASING INSTALLED: (H) PERFORATIONS:
<br /> Steel❑ plastic CCuncretr 4 T)rw of perfnratinn ur si-r of scrcrn - I
<br /> 1
<br /> To Slot —_
<br /> Pnnn To Dia. CaCc or from ft s:zc i
<br /> ft. ft. in. Wall ft.
<br /> G 95 6 160 75 55 . Tree.
<br /> (9) WELL SEAL: — _ —
<br /> 5
<br /> Was surfer sanilaq•seal Provided:' Y_s Nn
<br /> _ I
<br /> \t'erc stmt, -led .,am,t ,ha i„n: )-c, ;:J Nn ,- Ldrn:d ft. J u^ (;nmPlrtnl---. IA l
<br /> Meth,d u( sea4n,l_J 0 n L)n 1 t -- \fork ,tartest
<br /> (1C) NATER LEVELS: WELL DIi1LIXICS STATF\tEAT:
<br /> It This ¢r7I u'w drilled nnrfcr our mrkdiatinn and this rrPart is In¢ In best N n:g
<br /> Drnth of fiat water, if knr•wa ---- S; !t. Am^a leder and hrlrr'1
<br /> C..nsi nv. c rl Ale, ell r q t ti n
<br /> 7 11) WELL TESTS: SIrnFD_
<br /> (l\'ell llriL'u,
<br /> \t'a> we11 te•t made:' Ye, - N.,`� Mader r'` wh,:cn- -Air Irft�., I IiF►tI.I'•GS CROS_ Lt I!LIK CO. ItIC.
<br /> T.pr of •r+t Pump - J \:•:\[�-._- anted)
<br /> nd -•1 tc.t__-ft 1'•n,•n,fim or av rp.•uti•+n l .T)Irrrl nr P
<br /> D••pth to Hater ., st+r •.1 teat_-_It At Fj'�'r '�t l �1' '[i,1 j_ ti it 1-_
<br /> ;,tiler„
<br /> cal nun ancr-_�„un t\atrr h•myran:rr_� -' - �Qj�f1 pp AA
<br /> Disdsarce ,;.,. ,r1 `e ” ---� tjl! rC7 1JC:`r
<br /> �* V
<br /> rhos 1 anal,.,s ma,tr'• 1"rs N•• if >o, by whow?--_ --� (,1'L, _Dets••d this minrt_.
<br /> \'r• N,. li ..•. .,..,+•:h a.,.n d rcP•rt —� Lnrn•.r \.,._____-
<br /> G'NR+et) Jnr': '-r'•• IF ADDITIONAL SPACE is NEEDED. USE NE
<br /> IF
<br /> CONSECUTIVELY NUMBERED FORM
<br />
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