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L.UU^I Ivt. ,..r — <br /> 0AIGINAL WATER WELL DRILLERS REPORT Do Not Fill I" ` <br /> Fife Original,Duplicate and Triplicate with the (Sactwais 7076,7077,7079,water code) �,\? 14281Q') <br /> REGIONAL WATER POLLUT N <br /> STATE OF CALIFORNIA State Well No_... _ r <br /> CONTROL BOARD No ��' Other'Well'�o �,/ s— <br /> (faarrr syprop:larr armhnt �� • <br /> f <br /> OWNER- (11) WELL LOG, _ <br /> Name `� Total depth 4 it Depth of completed well <br /> 4�& <br /> Address v Formation Describe y co <br /> be blor,ebar.rter,size o nesterr.l,and st•ucrrre <br /> 1,57.f3�c_ r, <br /> it to ft ,s <br /> (2) LOCATION OF.WELL• <br /> pwnt!t number If iRt'—"' <br /> R F n or sWct No <br /> t�- <br /> X�L�Nl: sale <br /> (3) TYPE OF WORK (check). v <br /> New well L+l' Deepening E] Recondtaontng El Abandon El = C — — F <br /> i ^ten <br /> if abandonment,detcrtbe rnatrrtal acrd procedure to Item 11 t v o <br /> dLq <br /> (4) PROPOSED USE (check) (5) EQUIPMENT: <br /> Domestic [R-Industrial [_1 Municipal ❑ Rotary 0 <br /> Irrigation E] Test Well ElOther EDCable <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE MADOUBLE i? Gage <br /> or Demeter from to <br /> From Qft to oe.-t ��eam f all of Sore 2-ft j�7-Y,/fe <br /> 7 ype and site Rf shoe or well r'sts Sue of gravel <br /> Deseesbe fast / f <br /> (7) PERFORATIONS. <br /> Type ofperforator used G( <br /> SLU of perforations r in length by f J sn <br /> From % ft to f, Perf per row ! Re—per it <br /> (B) CONSTRUCTION. <br /> Was a surface sanitary seal provided? U!r Yes 4� No To what depth a ft <br /> Were any strata Sealed against pollution? U' e" ❑ No If yes note depth of strata <br /> From `� <br /> it to Sl ft <br /> Method of Sealing j<� � _ e— ___ Work ir.rfed Completed lysf <br /> (9) WATER LEVELS: WELL DltILLE STATEMENT <br /> This well runt drilled under my jurisdiction and this rrport is true to the best of <br /> Depth at which water was first found Ir 2 it my knowledge and belief <br /> Sraadsog level before perforating it NAME �J' <br /> ding Istel after perforating f is usoR car wrptrattmt t I yp,d or prsatedl <br /> Address <br /> (10) WELL TESTS: <br /> Wu a pump test made? ❑ Yet n-l" If Yes,by whom? �- <br /> [SIGNED] <br /> Yield ....�"'" Ital/min with .rte ft draw down after _.+ hn WeR Dr£lf _ <br /> Temperature of water Was•ebemiul analysis hada? ❑ Yea (-}•!Popop <br /> License No DAted_ <br /> W ist electric log made of well? 0 Yet n 95509 a 6.aDM Qum Q BVo DWR FORM No 29G IRav 3 t5,N1 <br />