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T1l�i4 NOT CHECKED <br /> ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill Ix <br /> File 0691 al.Duplicate and Triplicate wHk the (sectio..7074,ion.7078,renter code) 1� ? 36861 <br /> REGIONAL WATER POLLUTION svte Well <br /> CONTROL BOARD No STATE OF CALIFORNIA ^� <br /> .surf r1}+o}ri.tr srebrrl � '�Y Otber Wc11 rio.—� <br /> (1) OWNER: (Z 3) WELL LOG: <br /> Name - ��� A Total depth jJ fr. Depth of rnmpleted fell ft. <br /> Address 7 �' � � �_ r1 Formecioa: Dr—bw b7 eolm.che,"I •,rr,c of.sloth[,a"strsctsrs. <br /> ft.to fe. <br /> (2) LOCATION OF WELL: ' �'•'t'� '; <br /> r <br /> C,nrntTf,��`y A.1�_ yl1:! CY+rave nnmbv.if aoT— f ,l `r! ,y;. <br /> lt_F.D.or Street No. 1 ;^� � 1 /l— <br /> I e�.� � �t.r t'y ? �_t" �_t�fF , ;r t ,� ,r'� -. .. < �' �.� «' - ,d. �{+°'.,ts •,e't r. ! +,?. '�, <br /> (3) TYPE OF WORK (check): <br /> New%Fell X Deepening ❑ Remaditioning 0 Abindos ❑ <br /> if obandyreneent,describe materiel and grocedxrr in ltrrn 1I. <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: " <br /> Domestic 14 Industrial ❑ Municipal ❑ Rotary <br /> Irrigation ❑ Test Well E] Other ❑ Cable (� <br /> Dug Well ❑ <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLE DOUBLED Gaffe .. <br /> or Diarnrna fres ea <br /> From ft.ro fc Diam. W.H of Bon ft. ft. <br /> Type and. of.hoe ar re11 ring' _ Size of sraVel: .- <br /> (7) PERFORATIONS: - <br /> Trpr of perforaw-used .. .. - <br /> Size of perforaeiona �,length.by to rT n R N T I A L <br /> Fran ft.to ft. Perf-per ra. xow per ft -- . — — — <br /> d <br /> (8) CONSTRUCTION: fMY <br /> 1 <br /> 1w.s rorfacr nain,y cal prosided? 16 Ya 7 No To vlmt depth fe ,• <br /> Vere=1,rtraa sealed sSainat poilotion? Q Yet 0 No 14yes.aou depth of m.0 .. .. <br /> From ft.is fr. <br /> Method of Sealing- A1'Lff✓ Vwk rusted v Camplet" �1 >,S S <br /> WELL DRILLER.'S STATEMENT: <br /> (9) WATER LEVELS: <br /> This well was drilled mndrr my jxrisdictiox and thio rrport is trse to the bast of <br /> ne9rn at.bieL wen y.a.5m fa�sd n• >wy knowlyd rand& t <br /> =-sadm�Ir.d brfen perforatini _,r f ♦ ft. NAME <br /> 1RG6bj irrd after perforstins��,�✓f_,1�.r.'� ��t'_d l�^� _r .-.t-1 1 'n `` lt.. lF'cr rm1. r c r c� � 1I7DrJ ar 8ns.erll . <br /> Address c //�/'}� . ^ a <br /> (I 0) WELL TESTS: 22 , <br /> was a pe=p ret msde? C Tn 0 No If Tn,br whoent •• <br /> [SIGNTD] <br /> Yirid: Fal-/min.Citi. it.drams down.turf bra. Qafx well Drfffrr <br /> Tem,4erarere of weer 'Vu•eer>eial antlTaie male? [3 Yea �] ttio License Nm `!� — Dated_ - 19 <br /> 's-a electric Sas muds of wdl? 0 Yew 0 No seers s-ser sow ourN 0 sero DWR FORM No.210 cR[Y. 3-34) <br />