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r <br /> ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> THE RESOURCES AGENCY <br /> 'ile with DWR DEPARTMENT OF WATER RESOURCES NO. 079460 <br /> of Intent No. WATER WELL DRILLERS REPORT state Well No, <br /> ,,..:al Permit No. or Date Other Well No0IN06AG/A C=62: <br /> ( 1) OWNER: Name Calif ornia watervi (12) WELL LOG: Total depth ft. Depth of completed well ft. <br /> \ddress Post Office Box 1150 from ft. to ft. Formation (Describe by color, character, size or material) <br /> ;ity San Jose , CA Zip 95198 - <br /> r�) LOCATION OF WELL - t 18' . Filled <br /> Co San Joa uin (See instructions): Sta 4.1 k mix ter consultation <br /> County Q Owner's Well Number <br /> Veil address if different from above across from the and approval of L Hall, Director <br /> Township Garfield Fool , 166th. Environmental Serve , San Joaquin <br /> Distance from cities, roads, railroads,fences,etc. Local-Health tri (-'r <br /> - v <br /> r - <br /> (3) TYPE OF WORK: \ <br /> New Well ❑ Deepening ❑ <br /> Reconstruction ❑ - <br /> Reconditioning ❑ \ - �� \�/� <br /> Horizontal Well ❑ \ - �., '� <br /> r Destruction Z (Describe � - .• (� <br /> destruction materials ax%i <br /> procedures in Item 1, y <br /> (4) PROPOSED\USE. <br /> �{ Domestic �\ <br /> t T Irrigation,!�.\ _ ��.� - `i • �^�. <br /> Industrial \ \ ❑ <br /> Test Well �'✓ 0 <br /> t�^��'1�D Ol. Stook `` - �'\✓ .. <br /> S1 Lr14 srizt- !V Municipal\• Q <br /> WELL LOCATION SKETCH Other ❑ -`�—\`% <br /> 'f3) EQUIPMENT: (6) GRAVEL PACK: - <br /> Rotary ❑ Reverse ❑ _ es ❑ No'E Size - <br /> '.able ❑ Air ❑ �\ \ ter of bore <br /> r)ther ❑ Bucket ❑ Pa�om(7 i CASING INSTALLED%, _ (8)-PERFORATf6-NS: - <br /> teel ❑ Plastic ❑ Cno'7etA.Q Type of perfoi'a8on oosfze of screen:-.\ - - <br /> r From To Dia. Ghe-& F \ To `< „ <br /> ft. ft{ in. Wall V ft. /< \ s zap _ <br /> Y <br /> (9) WELL SEAL: - <br /> Vas surface sanitary seal provided? Yes ❑ No `; If yes, to depth ft. - <br /> irNere stratit sealed against pollution? Yes ❑ No ❑ Interval ft. - <br /> Method of sealing Work started-June 2219 Completed laY1e 19 <br /> 10) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> depth of first water, if known ft• This well was drilled under my jurisdiction and this report is tore to the best at ny <br /> 'Standing level after well completion b` t. knowledge and belief. <br /> (11) WELL TESTS: SIC-NED <br /> Vas well test made' Yes ❑ No ❑ If yes, by whom? (Well Driller) <br /> Cype of test Pump^, Bailer ❑ Air lift ❑ t NAME Clark Well &E'q uipment Co. , Inc. <br /> rJepth to water at start of test ft. At end' of test ft (Person, firm, or corporation) (Typed or printed) <br /> =e gal;min alter hours Watcr temperature Address 2 2L Fast Charter Way <br /> _al analysis made? Yes ❑ No ❑ If yes, by whom? City Storckton, Ca zip 95205 <br /> •Vas electric lug made? Yes C:) Na " If ves, attach copy to this report License Nu, 3/15 6 0 Date of this report 1 5 Jul 8� <br /> v <br /> DWR tee (REV. 7.76) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> r <br />