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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File Original Duplicate and Trlpllcafe with the (5ect.oaa 7076,7077 7072,War—ewde) ,N° 55270 <br /> ? <br /> REGIONAL WATER POLLUTION w.. „ <br /> CONTROL BOARD No <br /> STATE OF CALIFORNIA Sate Well No <br /> r!appropnele>e mbrr) Other Well No <br /> 1) OWNER (11) WELL LOG <br /> ame r <br /> Tatal depth Z,Z Q ft Depth of completed well Z fi <br /> Address Formatton Dez—be by color rheracirr rrsr of rwerrrfer and otrrulare <br /> • <br /> it to it <br /> (2) L CATION OF W L p <br /> Count r <br /> Owner t number of any— <br /> R F D or St it No <br /> Q t <br /> / �Zo <br /> ' (3) TYPE OF WORK (check) T <br /> New well ❑ Deepening IN Reeondittoning ❑ Abandon ❑ <br /> If abandonment,describe material and procedure in Item I1 <br /> (4) PROPOSED USE (check)- (5) EQUIPMENT- <br /> Domesttc ❑ Industrial ❑ Municipal ❑ Rotary ❑ <br /> ' IrngationTest Well ❑ Other El Cable <br /> Well Dug E3- <br /> (6) <br /> (6) CASING INSTALLED If gravel packed <br /> 1 SINGLE C4 aOlibLE Gam <br /> or <br /> Demeter from to <br /> From it to it Dum 'Wall of$ore it it <br /> Type sad tate of shoe or—11 ring 14e 5tre of gra—1 ` <br /> Dncnbe Ioowe <br /> (7) PERFORATIONS: <br /> ' Type of perforator erred Z- <br /> SIZ.0 of periarattoor to length bT w <br /> From ft tn it Perf per rax Rnwa per fc <br /> .s <br /> r- <br /> y�v c <br /> (8) CONSTRUCTION. <br /> r <br /> Nu a sar(a"sanitary seal prewaded? ❑ Ya �'r "'1• <br /> ❑ Na To whir depth it <br /> 'Fere any strata reeled agataac poilocton? Yet ❑ No I(ra ao a depth of strata <br /> From (t it <br /> 8 <br /> Method of Sealing - - Workatartcd 7r / _ is6p Complrred 7. <br /> (9) WATER LEVELS: WELL ]DRILLERS STATEMENT <br /> ..iter was lint iaawd ft This well woos drilled under my jurisdiction and this report is i(-e}6 the best of <br /> Depth at.hath <br /> O myknoWledgeandlbelief / �} <br /> " -.Z.Ic.el before petfarains ft NAME /J a�iC _LJ '& Y "tea <br /> tag level after perforating ft (Yrrson 6rm or corperao—1 iTyDrd or prrwird) <br /> Address <br /> o) WELL TESTS: t <br /> vsr•pomp int made? ❑Yea ❑ No if Y. by wham? <br /> Yield gal/—a with it draw down afar hra [S14NED] _____— _ — <br /> We[!Drill <br /> Temperatare of water Was a ehemtu!aaalyau made? ❑ Yes ❑ No License Nm---_— —_ Dated— —' ,19 V ter elect—log made of well? ClClYet ❑ No YY - _ <br /> 67025 4 57 EOM QPIN Q SPO DWR 1Hfi.(Reif 3 541 <br />