ARCHIVED REPORTS XR0000015 - Laserfiche WebLink

Home Browse Search

' ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In File Original,Duplicate and Triplicate with the (stctions 7076 7077 7078 Water Code) NO 67147 REGIONAL WATER POLLUTION I CONTROL ]BOARD No STATE OF CALIFORNIA State Welt No �. 3� �v ' ar- Y insert rpproprreie number) O C Gf Other Well No t I) O R. Name / (1 l) WELL L Total depth ft Depth of completed well ft Address Formation Dr,tbr by color,cfsneeter,carr of matsrsal oud strertvre it to it (2) LO ATION OF WELL County net s number if any— R F D or Street ' ' (3) TYPE OF WORK (check) f _Z New bvell X Deepensng ❑ Reconditioning ❑ Abandon ❑ If abandonment,describe material and procedure in Item I1 (4) PROPOSED USE (check) (5) EQUIPMENT. Domestic Is Industrial ❑ Municipal ❑ Rotary ❑ ' Irrigation ❑ Test WeII ❑ Other ❑ Cable ❑ Dug Well ❑ (6) CASING INSTALLED If gravel packed SINGLE DOUBLE 7 Gage ' r D-11., ro t from to From ft in it Mum Wa11 of Bore ft it ' Trpe and sire of shoe or veli nn Size of gavel Describe point (T) PERFORATIONS. ' Type of per£wzto-used i S'Ze of perforations o lonsch by an From ft in cPerf per row R.—per it (8) CONSTRUCTION: Was a sUrfaee Iae,tary seal provided? &a ❑ No To what depth // � ft ' mere any strata sealed against pollution? ❑ yes ❑ No If yes nate depth of strata From ft to it Method of Sealing / -- work reacted Complexed ]9 (9) WATER LEVELS. WELL DRILLER'S STATEMENT Depth at which water .fiat found well was drilled under ray?urisdretion and this report is true to the best of wait my knowledge and' belie Sti¢dlnR level before perforating f , it NAME %r./: Jin;level after perfontmR [t { raon hem or curp�rac,un i It t / y or D ted) Addrq ( ) WELL TESTS: Was a pump tett made ❑yes ❑ No If yes by whoms Yield Fal/w¢ with it draw down after hn [SIGNED] Well Drilfer Temperature of water WAS a chemical' analysis made? 0 Yes ❑ No License No _ _ Dated _ _ , I9 WA elrctne log made of welt? ❑ Yn ❑ Na t 570;7 6 07 70M gtllN Q SPO 3 EI MWR 189 (REV 3 34)