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LQ <br /> ORIGINAL WATER WELL DRILLERS REPORT " no of rn <br /> Fife Original,Duplicate and Triplicate wird the (s•ruoas rale,7077,70711,mats Cad.) 5c:ce pP�i No <br /> DIVISION OF WATER RESOURCES -� _ <br /> P o sox 1079 STATE OF CALIFORNIA—DEPARTMENT OF PUBLIC WORKS ! <br /> SACRAMENTO S CALIFORNIA DIVISION OF WATER RESOURCES <br /> I Region <br /> DRILLER- person, m r rporacion) (S) LOC ION OF LL• i <br /> Wame i a Cuaaa <br /> Address T'p It F P or Street No yi 1ZX 7 _ <br /> OWNER 6 I ' rl-1y� / ' <br /> Name <br /> `� 4, /fr l� i AuC' <br /> Address (9) WELL LOG: �f 1 <br /> Torsi depth of Weil <br /> Formauoo Mention nze at nater ara+el-- <br /> it + <br /> (2) Proposed Use (Check) Equipment <br /> Domestic [ Industrial ❑ Cable <br /> f` <br /> Irrigation ❑ Test Well ❑ Dug Well <br /> Muruclpal ❑ Other ❑ Other ❑ f-V <br /> ♦ 1,41e <br /> (3) CASING: 44�f v <br /> _ <br /> it of sn r fib"/3x tattng left in .yell F t <br /> Typo and sate of Aas at well rang ' r <br /> f 4) PERFORATIONS: J <br /> rise of perforator Wed <br /> Perforated ft to �-�—+ ft holes per an <br /> ,r <br /> Diameter of perforations as length in <br /> (5) WATER LEVELS <br /> Was electric los made of wail? I] Yrs L. No If+es Attach Copy <br /> Depth at which water was first found f _ ft <br /> Standen` le+e1 before perfontung r i ft <br /> Stawdm; level aFter psrfonnn; <br /> ft , <br /> Nota your ohaervataon of any change an water level whale drips"; <br /> Iris s surface sanarnry seal provided? r •Li � �-`�.��'��� <br />' (6) WELL PUMPING 'T'ES'T' 'Work,carted I JL completed 4-7C/4 13 IP <br /> r <br /> capancT cal/men ft draw down Darr of Report <br /> WELL DRILLER S STATE ENT <br /> W30 well gravel packed? This well was drilled tutder my lurerdrrtron and tbrr report a tear to for <br /> sera any stat■sealed agaanst pollution? of rosy ktrowledge imal beilet <br /> Attach <br /> s emparracure Vas a eheenaeal ansilys.s made? copy tSIGNED <br /> ®dl Driller <br /> if ahandonsd was veil capped? <br /> By <br /> (7) TYPE OF WORK (check)• License No elamficatlon �— <br />' New well A Reconditioning of veil ❑ Dated 19: <br /> Deepening exx3cing Well ❑ 46370 7 31 lam'JUIN 0 apo <br />