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QUADRUPLICATE 4', Do not}ill in <br /> STATE OF CALIFORNIA � ��}[Use of comply with THE RESOURCESAGEN'CY'-' /17 (1local requirements DEPARTMENT OF WATER RESOUR I ? l9 2 . 24 ( 392 <br /> Notice of Intent No-- _ WATER WELL DRILLERS <br /> Local Permit No. or Date HEALTH H ell Nn. <br /> 1Ji s'i'R�(rJ"' <br /> (1) OWNER: Name Ray Altamimno 12 WELL LOG: 175 163 <br /> ((��((y�/��/q� LLTT ( ) Total depth k. Depth of completed wellft. <br /> dddres 309M S. A 33 frvm ft. to ft. Formation (Describe by m]or, character, size a material) <br /> n <br /> t:in cYs U11 Zip - 30-- clay & sand <br />' (2) LOCATION OF WELL (See instructions): 3 - 3 sand & =ravel <br /> —- <br /> Co.ty JNn Joaquin Ownces Well Number - c <br /> Well address if different from above $a <br /> 5U- <br /> Township Rang a1sp�Sectio sy .„ /� -1 O Cld <br /> Distance from cities, roads,railroads fenoes,etc Albert Dr. Lot 150 -1 gravel <br /> east of h 33 — 'end of drive 1 -175 clay <br /> (3) TYPE OF WORK: - <br /> New We114 Deepening ❑ - <br /> Rmoretmctinn ❑ - <br /> Reconditioning ❑ - <br /> Horizontal Well ❑ - <br /> DesWction ❑ (Describe - <br /> - destmction materials and it <br /> procedures in Item 12) - <br /> (4) PROPOSED USE: - <br /> Domestic M - <br /> Irrimflon ❑ - <br /> Industrial ❑ - <br /> Test Well ❑ - <br /> Strck. ❑ - <br /> Municipal, ❑ - <br /> WELL LOCATION SKETCH Other ❑ - <br /> (5) EQUIPMENT: is) GRAVEL PACK: {� - <br /> Rutary a Reverse LlYea Sl No ❑ Size Gravel - <br /> Cable ❑ Air ❑ Diameter of bore 11� - <br /> Other ❑ Bucket ❑ Packed - <br /> 17) CASING INSTALLED: (8) PERFORATIONS: - <br /> Steel ❑ Plastic Q Concrete ❑ Type of perforation or size of screen - <br /> Fmm ToDia. Gage or From To Slot - <br /> ft. f[. in. Wall ft ft. size - <br /> 0 6 160 143 163 screen - <br /> (9) WELL SEAL: �(� - <br /> Was surface sanitary seal provided? <br /> .��..YYe,�es.�����sv.;L��N.�oo 0 If yes, to depth�tt. - <br /> Wen, strata sealed against p,bW1a/�Ii�1.t6. N.Z Interval ft - <br /> Method of scaling Work Iamted 19 Completed 19 <br /> (10) WATER LEVELS: 19 WELL DRILLER'S STATEMENT: I <br /> Depth of first water, if known This well was drilled under my furisdiction and this report is tme to the beat al my <br /> Standing level after well completion- fr, knowledge and belief. <br /> (11) WELL TESTS: JL Slcrvm '�}} <br /> we, well test made? Yes ❑ No [I If yes, by whom? flennil gs trd it tfi )lung Go., Inc <br /> Type of test Pump ❑ Better❑ Air lift ❑ NAME <br /> Depth to water at start of test N. At end of test ftllUtl�($Pti�, A ra aped or printed) <br /> Docharge nal/mrn after hours Water temperature Address 1L/V. d <br /> 95356 <br /> Chemical analysis made? Yes ❑ No� If yes, by whom? City3 kfj+-82 <br /> Was electric Ing made? Yes ❑ No ❑ If ves, attach cop to this report License No. nate of this Tcfam <br /> DWR 188 Into.7-7el IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />