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IGINAL STATE OF CALIFORNtA Do not fill in <br /> THE RESOURCES AGENCY <br /> with DWR DEPARTMENT OF WATER RE50URCES NO. 47955 <br /> of Intent No WATER WELL DRILLERS REPORT State \\ell \u <br /> `-nnit No nr 1).t.__-q_us tomerermit� got P ])thee \\ell r+n <br /> 'ER time (12) WELLLOC- Tut l depth-5-ft Depth if completed M.L11 lr] [t <br /> P 0 Box—198 from ft to ft F1miatu.n Incuribc b+ colds ehiri(ter +ire or mater),]) <br /> Lathrop, Calif. zip Sand <br /> LOC TION OF WELL Clay <br /> (SeN tnstnlcnoty+1 <br />.tl a n Joaquin -0.,oer s \\ill \umber Q 67 Sand <br /> .,ddres• 1f drrlerent tram 8 ghr,+e 70 y <br />„lvp ll cti,c $c t <br /> T ctrue <br />,rice frucines rvids ruln.+d+ fences etc Ike Kinle Ave, 1-- C1a <br /> 1 mile North of Hwy 120 1 74--83 ,Sand <br /> lay & shale <br /> —L;—Lay <br /> (3) TIPE OF WORK ay & shale <br /> \eis \\ell7Z Deepening ❑ lV 0 Sand <br /> Reconstruction ❑ 170-1 1 <br /> ay <br /> Reconditionini [] -,a82-185-" rF�> \`&I nd <br /> Hr.numtil flet[ ❑ \. -1 72 n .+r Clay <br /> Destmiction (Describe I 2 <br /> destrucUnn rnitenals AAA <br /> 04 <br /> procedures in Item Lr-� - -� <br /> (4) PROPOSED`USEi 218— 0 <br /> Domestic 310-315 <br /> lr•i�vtmn x - <br /> lndustnal \ [] < - -- <br /> r ` <br /> Test \i elk \ , ❑ <br /> �i <br /> 4funiupal - <br /> WELL LOCATION SKETCH Other r ❑ �.: <br /> PMENT }� (6) GRAVEL PACKMon <br /> n ❑ Reverse Yes No`Q ]Seize - <br /> `� 2'8tl�v <br /> $ } <br /> e �] Au ❑ Dtivis�ter of bore�] <br /> \ ` <br /> r ❑ ucket ❑ `� ��d.from�._'tE - <br /> CASING IIVSTALLED}F1 (8 PERF ORA NS louvered <br /> Cc Plastic ❑ C11n Meta <br /> TN nE pe34� on nPylze of scree <br /> ron3 T Dia r P To i <br /> ft f to Wall ft4 Y x, s3 - <br /> 2 20 <br /> 20 ofvcreen - <br /> WELL SEAL \ - <br /> surface samtary seal provuled'� IesiEl No ❑ If +es to depth375 _k - <br /> c strati sealed ag-iinct pollutmn7' 1 es ❑ No 7, interval ft - <br /> nd of seahn R urk started 19 Completed-19- <br />) <br /> ompleted _19) WATER LEVELS WELL DRILLERS STATEMENT <br /> th of first w-tter if knosi Et This well teas drilled under mu tnrtsdecttnn and thn report Is true to the he+r nl ncy <br /> ding level after +cell completes 42 k Anomledge and belief <br /> WELL TESTS - SIcr,En <br /> ,ell test ma 'Dnller)e1i`.�rr4 <br /> de Yes (R <br /> No ❑ If )es 63 wham' ell <br /> of test Pump X Bailer ❑ Air lik ,\AAiF.�-en n ii Z <br /> ]}1 �—P ��a ori tl—o l�tecTl- �� <br /> th tel �+,'Iter 1t Start U[ test ft At cnd r,f lift <br /> r (PETS n firm or corporation) { vp [) tint <br /> barge 36959a1/min after hours \t,jter temperature Address52ri Pel andalQ Ave. <br /> meal analysis made Ye City Nodes to � l f 73p- <br /> Y s ❑ no � if yes b3 whom• <br /> tnc log made? Yes ❑ No If+es attach copy to this report License No 290$1 3 Date of this report <br /> R (REV 776) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 4321605077670stouw00T09F <br />