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Received Dec-29-99 09 48am from 227 7600 4 AOUA SCIENCE page 4 <br /> CENTRAL DISTRICT ID 227-7600 DEC 29 '99 10 29 No 002 F 04 <br /> ORIGINAL STATE OF CALIFORNIA Do not fill in <br /> File whir DWR THE RESOURCES AGENCY <br /> DEPARTMENT OF WATr&R RESOURCES � No. 27034 <br /> \utlLe of Intent No WATER WELL DRILLERS REPORT <br /> icujIt owe r, ha s permit Oche Well Nor� � <br /> 1i t Yenrtlt No nt pate %rR.ec!. <br /> 4 I Other well Na <br /> . (1) OWNER, Naoie Manual DeC osta (12.) WELL LOC Tvtnl deptl--2-C)$t Depth of completed w61230—ft <br /> Aiddrris Oi 9- V. 120 it to ft Fnrmntfon (Dcscribe by culut, Ltsirtcter, size or material) <br /> Cyte. n ��CJtJ� • Zip <br /> 1 2) LOf ■ tt++!((����f( <br /> •` 0F 'WELL (se, fnvtrut ions) <br /> Coiinly, 4Qu- a Owners Well Number - aand <br /> %%PH midym,i if differem fwni nhnVL � O cia <br /> T—,nship Rang Satlio 46 Sand <br /> MA VILE fnnu Cities roads,rriitn,nds fences,etc QSJLay <br /> (3) TYPE OF WORK, <br /> New Well= Deepening ❑ Ra nd <br /> Recnnztrs tinn ❑ <br /> Recondihoning ❑ <br /> Horizontal Well ❑ - 0 <br /> Destruction Q (Describe - � end <br /> dertructlnn mkt Ti 2-� �$ <br /> proc*dufa In IHm <br /> (4) FROPOSED - S�ICI3 <br /> Domestic - C <br /> I ort%atlnn�� - <br /> Iridusttlal <br /> Well 0 -221 <br /> st 21- la & <br /> hluntct - <br /> WELL LOCATION SK9TCH G+tltee ❑ - \% <br />. (3) EQUiPMEhTi (e) GRAITIL,PACK, <br /> Rotary ❑ fieverse lx X) ?n114 Sixe <br /> cahir r] Airof bare 11 <br /> ❑ <br /> tar r <br /> Clther p Bucket cl ` tom Q 210 \ <br /> (7f C.ASI\C INSTALLED (8 PERFORATIO N`St-1 d <br /> Steel fz Plastic ❑ et Type of pe n ut�lze 7SCte \ - <br /> Froin Tq> Dia r F �l To - <br /> ft f 1n Wall ft. si P <br /> U 2- <br /> (S) WELL SEAL - <br /> %1 as surface sanitary +enl provided? Yet$I No ❑ If yes, to depth--5V—ft - <br /> Wer* stroke settled a%tinst pollution? Yes 0 No a Interval Ft <br /> Ftethtxl of srttll Work stlrt -19= Com letecL 19 <br /> (10) WATER LEVELS, WELL DRILLER'S STATEMENT <br /> Depth of first writer if kno Ft This well was drilled under mu 11trIM(ction nrrd this rettnrt it true to the bets nl my <br /> Standin¢ level after well enmptetio R krrou.l)ds,e rind belisl <br /> (11) WELL TESTSi 1� H8 p`ruee)SIC"Eo Wat well test made? Yes+t,; No ❑ 11 yet, by whom' <br /> Typo of test Pump*? Biller ❑ Alt lilt NAM a <br /> Depth to wakes x! ■tart a[ tear x rl. At end of test_ - It Pr g1tian� nt€Qnv�ped or printed} <br /> llischirge � 20 t - Address 552� t' Q�i a .,-- -43 6 O <br /> gal/Tokio( alter ours Water temperature <br /> Chemicel annlvsis made? Yes ❑ No:1 If yet by whom? City -Modesto, _Zip <br /> frit low madr? Yes No If es ettich a To this rt Lironca\cx Date of this re <br /> wR 1E8 tsitty 7 7a1 IF ADDITIONAL SPACE IS NEEDXD USE NEXT CONSECUTIVELY NUMBERED FORM srts-•w„irtew evooCDr or• <br />