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)RIGINAL STATE OF CALIFORNIA Do riot fill in <br /> THE RESOURCES AGENCY <br /> Ile with DWR DEPARTMENT OF WATER RESOURCES No. 142189 <br /> 1~e of Intent No WATER WELL DRILLERS REPORT _ <br /> 1 7 a 12 5 21+1 - 4100 — State '%eil Two <br /> )r'ennrt No or URiP_ t � 1 <br /> Other <br /> �]�%e1] 10 y� <br /> 1 ER mm.. fF�(ria Jnr k Mendes (12) WELL LOG Total deptlL---.!-��7t Depth of c ompleted yell <br />!d•ess 1 `' 89 S a McKinley Ave . from ft to ft Fonnatrnn (Descnhe by ctliur ehara(ter stye or muenal) <br /> t. Manteca , Ca . Zip 0 - 14 Sand <br /> LOCATI�N OF WELL { ) 1 _ K clay <br /> San gJ Oaguin 5@f urstructiolls I Sand <br /> ntr ,_..,Owners Re111umber <br /> ell address if dillereilLfrom tbove 57{] <br /> — 71 Clay <br /> r <br /> n (r shrp Range Sectio Q 71 — 77 an <br /> ,tante from cities roads r ulroeds frnc�s etc 1")7,,,,f�c n2r e Ave.— — 82 aJ <br />-mile so th of Hwy_1201 west Side 102 - axe troarse <br /> 88 - 98 Clay- <br /> 8 - 100 "\Sand <br /> (3) TYPE OF WORK 100 r 110 ala <br /> New 'A ell X Deepening ❑ 1 10 Sand <br /> Reconstmetion ❑ 123 - Cla , -& shale <br /> Reconditioning — <br /> Horizontal %%ell ❑ — <br /> Destruction G (Describe — <br /> destruction matenalsand <br /> procedures in Item 12) — <br /> (4) PROPOSED USE - <br /> Domestic 19 — <br /> Irrigation ❑ — <br /> r <br /> industrial ❑ — <br /> Test Well ❑ — <br /> Stock C — <br /> Municipal ❑"qMW ELL LOCATION SKETCH Other ❑ - <br />,) EQLIPMEN11' (6) GRAVEL. PACK - <br />,tan 1K Re%ene ❑ les M \70 ❑ Size bird e e — <br /> rhle Q Air <br /> I 1! _ <br /> © l7ra>�eter of barey <br /> ��.,,((�� ��{ �'j�' oQ <br /> Cher ❑ Bucket ❑ Packa from— — <br /> 1 CASING INSTALLED - (8) PERFORA'nONS — <br /> cel ❑ Plastid] Con4reie ❑ Type of perfKanon or Size of screen — — <br /> Froin To Dia Gaged FrO I To <br /> ft ft in Wall ft fts>zg - <br /> 0 129 �� 1 - screen - <br /> 9) WELL SEAL ^r-� <br /> as surface samtarr seal pro%ided' Yes EZ No 0 if yes to depthft <br /> ere strata sealed against pollution" les ❑ No ❑ Interval ft <br /> tethod of sealm Work started 19 Completed 18 <br /> 10) WATER LEVELS WELL DRILLERS STATEMENT <br /> yxh of first %later if kno+% ft flus well was dulled under my jurisdiction and this report is true to the bcs7 of nr❑ <br /> I indmg ]eve[ after well uimpletio 19 ft l.nnwledae and belie <br /> i <br /> 11) WELL TESTS SIG\ED j? cc s- �, -C (SQrr<< T I <br /> $IN ell Drrllt r S / <br /> is well test made les ❑ No A if Nes bo µham' 7 T <br />,Ioe elf test Pump I❑ Baiier ❑ Air lift ❑ �BPos • I <br /> NAME��1117.1n�5 Drilling Co,� . nom_ <br /> repth to water at start of test ft At end of test ft (Person fine or corporation) (Typed or printed) <br />+ char a Water temperature Address^�5 Man. ale_ Aye. <br /> _ <br /> S gnl'min after hours w 7 Pe Mod a tO a Zip 0 <br /> a1 analysis made yes Ci <br /> ❑ No$� If res by hum � <br /> d <br /> ctnc tog made? 290813, Date of this relxi O <br /> � Yes ❑ No '�[ 1f %es Rttach copy hi this report License No <br /> e (REV 7 >ei IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />