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iIGINAL WATER WELL DRILLERS REPORT � Do Not Fill In <br /> I Original,Duplicate and Triplicate with the (S"rioaa 7076,7077,7071,Vfrscsr clrode) U 553117 <br /> !GIONAL WATER POLLUTION Since Well <br /> 4ONTROL BOARD No.— STATE OF CALIFORNIA -_ " <br /> -••t*pproprislr num8ert <br /> (1) OWNER: J (11) WELL LOG: <br /> Name --� � Taut dep[fi f�� _•ft. Depth of eomplctcd ael!_ <br /> Address � �/�a� �. r _f� � F-mvi— Describe by color,character,the of mdrriai,and rfrrrfxre. <br /> ' ft.to ft. <br /> — l ailrt <br /> ---------------- <br /> (2) LWATION OF WELL/ <br /> i... C ty Al_ c [)wacr'1 n mbcr,if a .. F.J •. �� <br /> e.aai <br /> Ro F.D!o,St, <br /> Q T �� • .. . <br /> �.. (3) TYPE OF WORK (check): <br /> New wdl OX Deepening Reconditioning E] <br /> l f'ab nd a:sncnl,desrribe mafrrial and procedure in Item 11. - — <br /> `,, (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic > Industrial ❑ Municipal ❑ Rotary ., <br /> Irrigation ❑ Test Well ❑ Ocher ❑ Cable <br /> Dug Well ❑ <br /> (G) CASING INSTALLED: If gravel packed <br /> S1NGI-EW DOUBLE, .--- <br /> o• Diarenrr from w <br /> From ft.ra ft. Dura. WA of nnre ft. it. <br /> Type and sire of shoo or,Pell ring .4� Size of flrarc:: . <br /> 1..� 1)rr.rilac ioiatr <br /> (7) PERFORATIONS: <br /> Type of yrrfnrztor nrd ' <br /> 6a SIZe of perfor:riaoa ., .ler <br /> r'romFs,rn fr. sperf,per row Rnn-s per ft. .. <br /> �.. (8) CONSTRUCTION: <br /> War a surface sari:try teal provided? ❑ Yes ❑ No To shat deprh fr: alt <br /> Were nay scuta sealed spinst pollution? Ycs ❑ No If yet,ante dePds of serua - - <br /> a. From to ft. <br /> Method Of Sealing - —- Work exacted l9 1 Completed 19 <br /> 16. (9) WATER LEVELS: WELL DRILLER IS STATENIEN'T- <br /> f This well was drilled under my jurisdiction and Ibis report is true to the brit of <br /> Depsh a xlsirh vaecr vas fire(Quad it. my knowlyd a rtd belief. <br /> `Zcandiag level before perforating ft' NAME <br /> 1 ell hf*A0 <br /> 7k level after perforating h, (Ycr 6rm, car pcnsiup 7 ,7 YPed/p,i red <br /> (10) WELL TESTS: <br /> W-z pump rest.,dr? ❑ Yes 0 No 1f yes,by vhom? <br /> [Sr�Nen]----------------... — — <br /> gal. mip. RI[11 ft. dra.r down after hr s. Well D "!ler <br /> Tcmprnturr of--aur VL'as a chrxniul analytic made? 0 Yes ❑ Na Liee cls[NO.____.----------.._ _..._....-..-.._ 332lCd ............. <br /> 4'ae eiec aie loR male of yell? C] Yee ❑ No <br /> �"a sTazs s-ti e0M QUIN'LSPO OWR 168 (REV. s-say f <br />