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DUPLICATE - WATER WELL DRFLLEY S REPORT Do Not Fill In <br /> e... File Original,Duplicate and Triplicate with the (Sections 7 07 6,7077,7072,Voter code) N� 55314, <br /> ; <br /> REGIONAL WATER POLLUTION cz _l <br /> STATE OF CALIFORNIA State Welt �r <br /> CONTROL BOARD No. � '� / <br /> ''�•crt sppraprfsee nr.mbrr) OCher WCII <br /> k I) OWNER: (11) WELL LOO: <br /> Name T-1 de [h <br /> ` -/",C�'� _.. p ft. Depth of complemd ,rel] J� f[ <br /> i..r AddL"CSS 7 ���'¢�� � Formariou: Drscrrbe by ro!0"cLerresn,size o/mrlrrial,end ffrerlssrr, <br /> — - ,•—._ ti- ISG fr. <br /> �.. (2) LO ATION OF WELL- <br /> . n mber,if rny—tY OwCnD .g <br /> d '� :fr r ,._ '� •• <br /> 4 r <br /> (3) TYKE OF WORK (check): <br /> Nrw well Deepening © Reconditioning ❑ Abandon -IT <br /> If abandonment,drsrribe material and Procedure in Item 11. — <br /> iie (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic N_Industrial ❑ Municipal ❑ Rotary <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable <br /> �. Dug Well ❑ — <br /> (b) CASING INSTALLED: If grave]packed _ <br /> SINGLE'V VOUBLE 7 Gage <br /> Mamater from .o - <br /> �„e From - ft.to ft. 2)ixm, V:xll of Bore it, ft. <br /> Tyrm end siu of.Aon es well ri n8 �`,. { Size of gr.t•el: •• <br /> (7) PERFORATIONS: ; _ <br /> Type of perfor.tor used -` <br /> i..e Size of perforations ia,length,by <br /> From <br /> ft.[. <br /> Perf.per row Rams per ft. .. .. <br /> V <br /> (8) CONSTRUCTION: <br /> �`as r surface s.aiu rq real provided? ❑ Ye. ❑ No To what depth f[. ,• <br /> Vle[e euy aerate veiled egilmr pollution? Yes 0 No If yn,note depth of.tr... <br /> it _. •. •. <br /> Froin ft.[o <br /> Method of Sealing 7 ark rt.rted <br /> ar - '... rt'Y ._- 19 Completed p 19 <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> This well was drilled under my jur➢dirtion and thisrrporl is true to,th'�ksl of; <br /> Depth it wbich voter we,Sr.[found it, my knowledge and 6rSIe), ? <br /> 1- -nd ion level before perforati.gr <br /> fr. NAME <br /> tix level after perfarating f[. (Yrrson,firm,or carparanou s r 7'rprd ar pr,,.rcJ) <br /> Address <br /> 10)(\10) WELL TESTS: <br /> � \a pump rc.t mrde) ❑ Yu ❑ No If yu,by whom? - <br /> 2('7 <br /> ! [SiGNE➢].---."------------------""-.- - <br /> \� K.Lr . vah f[.dr:w down .Ree hr., -"u-fytsx=__._._ _ ..... -."_ <br /> rfJ Dr ler <br /> `7rre of water Wa.ehcminl analy:is made? ❑ Yrr [3 NoLi - _ <br /> cense No. ....................... Dated---------- - B <br /> V+ r•e IDR rode of w'11? ❑ Y'. ❑ No <br />