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ORIGINAL STATE OF CALAFORN[A DO riot fill in <br /> THE RESOURCES AGENCY n� <br /> �ile with nWft DEPARTMENT OF WATER RESOURCES No. 098345 <br /> f Intent No MATER WELL DRILLERS REPORT <br /> r� State Well No <br /> uk;-[Permit No or Dnte ,_77 '836— Other Well No <br /> (l) OWNER t\rime$�fa e1, Ma r� (I2) WELL LOG Total il"O, 1 0 I Depth of completed we1L t�L It <br /> Addre . 212-37 Tracy Blvd• from R to ft Formation (Describe by color '.bar-tcter sire or material) <br /> city Trac CA p - o o' <br /> (2) LOCATION OF WELL (See rnstMcttons) <br /> County Owaees Well Numbe --15 - 2-0----s and <br /> W811 address if different from abov 20 - 21 Cla <br /> Township Range <br /> ,_Section__ 1 - ppO SanAxv, <br /> Distance from cities roads,railroads fences,etc V <br /> d O - O `61a V <br /> wile north -Qf Hj0 n est ide 80 - 8 and <br /> 4 - 16 finNf <br /> e sand <br /> (3) TYPE OF WORK- kl (� 2 <br /> N-- wen fx Deepeniag❑ 12 28 gravel and sand <br /> Rcconctrvchon ❑ 128 - O Cl <br /> Recandilionini: [] -- <br /> HoricontnI Well Q <br /> Destruction © (Describe <br /> destructtonmatenals a <br /> procedures fa Item 1 - 24 <br /> (4) PROPOSED 9> <br /> Domestic <br /> Irnptatron t a _ <br /> T <br /> Well /1 ❑ ._ <br /> SI <br /> Mumclp � <br /> WELL LOCATION SKETCH Other ❑ <br /> (S) EQYIIPmE%-r (e) G ai PACK, W"" <br /> Notary 99 Reverse ❑ X No Sl <br /> Cable Q Air ❑� ter of hem <br /> t <br /> Other [3 Backe ❑ � o w. <br /> (7) CASING INSTALLED (8) ERFOZtA*4 Sr <br /> Steal Q Plastic ❑ Co c Type of per + qrt ar pfze of scree <br /> From To Dia G-9-- r F To <br /> ft ft to Wall f ft s�z <br /> 0 160 <br /> (9) WELL SEAL _ <br /> Was surface sanitary seal prowdeda Yes No ❑ If yes to depffi !�O—ft <br /> Were strata sealed aglinst pollution? Yas Q No Q Interval. ,ft <br /> Method of seollni- Ben�Q ite �Vork shute I9 Completed IrJ <br /> (10) WATER LEVELS WELL DRILLER'S STATEMENT <br /> Depth of first water if knower _ _ ft. This well was drriled under my tnrtsdictran and this report is tree to the best of my <br /> Standing level after yell completion f� ft Dlnowledge and b lief <br /> (11) WELL TESTS SIGNED <br /> Vas well test made' Yes ❑ No N1 If yes by whom? (Well Driller) <br /> Type of test Pump Q Hailer Q Alt hft 0 NANIE HenningS Bras. nri Ilg <br /> CO Trac <br /> �.l— <br /> Depth to water at srtrt of test It At end of test tt_ I Person, fimt or corporatio>a) (Typed or printed) <br /> 0cvera e <br /> F90--gal/rain after hours Water temperah Address'' -15251 Pelandale—_. <br /> MI analysis rnadO Yes Q NoX If yes by whom' ClClty• Modesto.�WAA electric fog made? Yes [I No.0 If acs, attach copy to this report License No 2 081 I Dato of thio report <br /> DWR fab (nr:v 7 7a) IF ADDITIONAL SPACE IS NEEDED U$$ NEXT CONSECUTIVELY NUM RED FORFr ��} ' r x <br /> � i�`ie. <br /> tri <br />