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ORIGINAL STATE OF CALIFORNIA Do not fill to <br /> THE RESOURCES AGENCY <br /> Ile with DWR DEPARTMENT OF WATER RESOURCES No. 129413 <br /> re of Intent Nn 1 — WATER WELL DRILLERS REPORT _ <br /> Jr'ermtt Ivo or Date State Well �o _ <br /> Other Well ',oO _�_ � <br /> _ <br /> VL'1\TER N,n1f Frank ErgorilS (12) WELL LOG1l0 ,110 <br /> Hwy. <br /> depth ft Depth of complete[l s,cl ft <br /> ildres. 10 L. HW . 120 In— ft to ft Fomlation {Descnbe b} color character cue �,r omit--) <br /> Itiianteca Calif. Zip - 4 6andy–topsoll-- <br /> LOCAJION QF W an anKay layers <br /> ,,int, 5 an J oa�uin seg �t�slft��t,or„) -Z1- 5b Clay Drown <br /> _.._Ou neo s ]�clI \uulher <br /> Lll tddresa if different from above - $1'1 , parse an ro n <br /> .+nshtP R1nt,e L Set' - ay,t <br /> Vance from cites meds rvlr,zd+ fenLcs etL 35Mw+7 - <br /> Manteca. 300' 0. of wy. - .coarse and blue <br /> (3) TYPE OF WORK ri \ <br /> ?J/ a New Viel]X Deepening ❑ - <br /> Reconstm c-tton C <br /> Reconditioning ❑ _ - t <br /> L r Horizontal 1A ell ❑ _ <br /> ' Destruction ❑ (Describe - <br /> ] destruction matenals and <br /> v procedures in Item 12) - <br /> (4) PROPOSED USE <br /> VO— L I Domestic YE — <br /> ' lIrrig'ttion ❑ _ <br /> Industrial ❑ <br /> Teri well ❑ A proper wel cover was zns a e-d— <br /> i <br /> Stock ❑ on- 1s we an am no response e <br /> Municipal , Q or ;-any altering or removing o e <br /> WELL LOCATION SKETCH /` Otber - ❑ sealE-or oaz3tng. <br /> 5) EQUIPMENT (6) GRAVE&PACK <br /> utiry Reverse \ <br /> ❑ les 2; No ❑ Size D e <br /> role O Au 1211 <br /> [] 11aagZeter of bore _ <br />[her ❑ Bucket ❑ Packed{rom_.- _to 110 F _ <br /> t � <br /> y CASING INSTALLED i ((s) 7'ERFORATIOI;S - <br /> I \ <br /> Le] ❑ Plastic .� Concrete ❑ w� Type of pe a or 3i'ceuo screen - - <br /> Froin To Dia Gage—or Fx `' To �SlatJ�� _ <br /> ft ft lit Wall ft ft tae _ <br /> 0 11 0 P I 90 110,,-,,, "x - <br /> w <br />)) WELL SEAL _ <br /> Is surfue sanitari sea] proudeO les ® \o L,7� If yes to depth—_Cl _ft - <br /> ere strita sealed igainst po))utnn° les [] No kQ ]nter.al ,ft - <br /> tthod of scaling—Cement <br /> Work stern 19 L Cnniplet 19 1. <br /> t0) WATER LEVELS WELL DRILLER'S STATEMENT <br /> pth of first —iter if l.nonr� `7 <br /> ft Thrs weel uas d under rny aAsdut and Iles repaid i frr fu th, low of my <br /> ending lesel after well completion ft knowlectAc-rid b _ <br /> 1) WELL TESTS St( v>ED <br /> — <br /> is cell tcct oitdt, ]Ls \cr gr )f %t, b% .+h-n� (Nell Driller) <br /> Pe of tut 1-11111pLlBasler ❑ Air lift ❑ DAME Parer Well -Drill ; Inc . <br />-pth to eater it stlrt of test ft At end of test ft )(Person firm or corporation) (T1ped or printed) <br />�.harge _go]/men ifter_ hours W iter temperature Address 14F 0 E• Lone Tree Road <br /> rl analysts made? Yes [] No ❑ If yes by whom? City Oakdale, Calif.,-, iP 9 3 1 <br />'fookctric log made? Yes ❑ No 0 If ces 1tt-tch copy to this report License Nn 1latE uf4 [�r{rpo � 12 I " <br /> t3 (REV 7 76; IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />