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,I <br />� STATE OF CALIFORNIA <br /> .iNAE THE ]RESOURCES AGENCY Do not fZt! to <br /> .le with DWR DEPARTMENT OF WATER RESOURCES rA ^ e- <br /> WATER WELL DRILLERS REPORT No. <br /> ice of Intent No State"'ell No <br /> gift Pernrit No or Date7 � 0 <br /> Other %'1'cll No, <br /> (1) OWNER Name Qccident&l -ChemicalCo. — (12) WELL LOG Total depth 14 ft Completed depth <br /> Address 16772--Eouth HoWlandFrom ft to ft formation (Describe hs color character size or malertal) <br /> CM Lathrop. California zip 95330 - <br /> t 2) LOCATION OF W ELL (See Instructions) 15 C12Y <br /> — <br /> CA)wity _ ;Anjoaquin O%kners %Nell \umber — <br /> %%ell address if different from above 26 - 137 rlqy <br /> I os%reship Range Section <br /> Distance from c itics roads railroads, fences etc <br /> West of Mendes Dairy - ^ <br /> (3) TYPE OF WORK — ~� <br /> New Well 29 Deepening ❑ <br /> iReconstruction ❑ �' `� `� <br /> Reconditioning <br /> Horizontal Well ❑ — ' <br /> Destruction ❑ (Describe <br /> destruction materials and pro- _ ! <br /> cedures in Item 12) <br /> (4) PROPOSED US <br /> PDomestic _ <br /> IlkIrrigation <br /> industrial , � ❑ l�` _ �, '.� <br /> �. <br /> Test "'ell �\\ ,1 ❑ <br /> MunlciN\ ❑ ✓ J , <br /> l/ 7_` <br /> WELL LOCATION SKETCH <br /> tom} EQUIPMENT RAVE <br /> I- CK <br /> Rotary R1 Reverse Ll < No M Size, <br /> Cable <br /> ❑ Au ❑ Nese oEbare <br /> Other ❑ Bucket'--l� �c d rom Q <br /> (7) CASING INSTALLED (8) PER \[ONS — <br /> Steel$] Plastic ❑ n Ty of Fo on or size Of _ <br /> From T I Gage or `\ `rig\ </6t <br /> ft Ft I Wail ,KtY size 14o b0 <br /> i <br /> t9) WELL SEAL — <br /> WassurFacesanitarysealprovided? les 29 No ❑ If yes,lodepth 140 FI Were strata scaled against pollution? 2 es E) No El Internal Et <br /> 6lethodofseAngCement rout Work starts 19____ .nmpleled 19 <br /> (10) WATER LEVELS WELLI 1 ER'S STI(TIR M <br /> Depth of first Nater if known FI <br /> St�ndmglcvelaftcrwe[lcumpletion luThis f1 5 !!c rude tri lee i is n a d e r t' t is u to the <br /> ft st oftu�my ed <br /> (11) WELL TESTS S,g„o-d <br /> Was well test made )r3 ❑ No El It yes by wham Well ll eller) <br /> of' <br /> estPt,n,p ❑ Bailer ❑ Mrbft Ll NAME Clark Wel &? r U ment CO . Inc. <br /> b to water at start of Ift At cndof Icsl ft4 (Perso olCar raan?(Typed or panted)) <br /> rge gal/min after hours Water temperature Address tt <br /> Pr Way <br /> �y <br /> 0-cal analysis made? yes E] No ElIF yes,by whom? City zip�9 i2_15-- <br /> Date <br /> 2_ 5Date of this rc port <br /> DwR ISO(REV 12 861 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 06 916355 <br />