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TRIPLICATE STATE OF CALIFORNIA <br />Owners copy THE RESOURCES AGENCY <br />DEPARTMENT OF WATER RESOURCES HLALTHNo. <br />rr`{. <br />'•It+.r of Intent No._ --- -- - WATER WELL DRILLERS II 1�F R '; i /SEh`l'S us Well No <br />,ocal Permit No. or Date 1_1Z -- Other Well No. <br />Do nl)l hll in <br />Mmm <br />1) OWNER:Name W i ] i aw► illtriLY]_�3 & (12) WELL LOCI: Total dWh U7__ t. Depth of completed weii-16(bh. <br />r...... q r.. (+ Fnrtrtatfnn I r hasertbe by nelor_ character_ sts:e or material) <br />an ress �r �-� -. --- - - <br />:it,. 'Tracy. ilii. 95375 zip <br />2) LOCATION OF WELL ( See instnictions ): <br />'warnty c TOwner's \V 11 NZrit) <br />Fell r t V�i'`clin, C1.��aZ10 x11IL'� <br />ownship `ACV RanK 1 Set,tirm_ <br />')i.tance from cities, roads, railnrads, fcne�s, etc.__.__ _ <br />- <br />_ <br />grown <br />' <br />- 24 <br />gig <br />a (�t^��� <br />�� S4 raVel(� <br />4 95 Ucti tin L- <br />')5 97 G raw3l <br />- <br />:i clA <br />IU4- <br />107. `\ Gravel <br />t] <br />(3! TYPE Or «'OP.I(: <br />New Well IM Deepening <br />Reconstruction <br />Reconditioning <br />Horizontal Well <br />Destruction ❑ (Describe <br />destruction materialspnn-edures In Item(4) PROPOSEDIrrigation, , ;;\ <br />Indo.trial \\`\• <br />TOK Well C3 <br />Stuck <br />Munici'M ❑ <br />Other \ ❑ <br />107 <br />? 1 <br />, "1 CIA <br />Graygal <br />IircibY cla <br />� <br />- , ' <br />l s `s <br />y <br />El <br />�� - -- <br />.`._\ - <br />- <br />WELL LOCATION SKETCH \ <br />- <br />(S) EQUIFMENTI <br />Rotary Revere ❑ <br />Cahle ❑ Air ❑ <br />(kller ❑ Bucket ❑ <br />(R) GRAVhl. FACKI \ <br />Yes (a No Si. <br />01Weter of Ixlle 12- <br />Paal*ed,Im_y�iYiL-tfo� 160_�t• <br />- <br />- <br />- <br />(7) CASING INSTALLED:(e <br />Steel ❑ Plastic K] CntV,-N#e <br />(R) PERFORATIOMS: <br />Type of per(oratinll or she of screen <br />- <br />From To Dia. Gage or <br />ft. ftk', - in. Wall <br />From To <br />ft. ft. <br />5}ot <br />Size <br />- <br />--_ <br />"Imp <br />16m <br />PSI <br />(9) WELL SEAL: <br />Was surface sanitary seal provided? Yes?Q, No ❑ If yes, to depth - <br />Were strata sealed against pollotium? }}Yew�s � No ❑ Interval Jt. <br />Were <br />Method of sealing_ Timto ite <br />- <br />- <br />Work started 19 <br />C.omplet I4__-.--- <br />(10) WATER LEVELS: WLLL UtULLe.na aintcmc.t.�: <br />Depth of first water, If known -- —ft• This well uxu drilled under my turisdkYion and thio report it Ince to the best of my <br />Stalling level after well completio km)wledge and helfet. ,..y(I <br />( 11) WELL TESTS: SIGNED ��t) /� X-� l <br />War well test made? Yes ❑ No El if yes, by whom? ClLue} <br />�•s.� �( Well Driller) <br />Tyloe of test Pump ❑ Bailer Air lift ❑ NAME � '^"`-xuw Cb. a Iwo - --- <br />Depth M water at start of test h. At end of teat ft (prrsun, firm, or corporation) (Typed or panted) <br />U - <br />Discharge cal/min after hour Water tenlloerahlre Address 30 S �4£I ly CC'' <br />Chemical analysis made? Yes ❑ No ❑ If ye+, by whom? — <br />City rl�]tti [lfsif _ f :f 1 -if _ _Zip_9yaU__ <br />Was electric Ing made? Yes ❑ No ❑ If yes, Rtt:lch copy to this report License No 371252. Date III thio nport_s <br />own 186 (ngV. z•ze) IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />