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l4/�'°N) STATE OF CALIFORNIA <br /> Fne 0rlgln, Isglrtate and Triplicate with the <br /> DIVISION Or WATER RESOURCES — _ _ _ DEPARTMENT OF PUBLIC WORKS SHEET 1 <br /> _ _ _ _ _ <br /> SACRAMENTO S CALIFORNIA DIVISION OF WATER RESOURCES <br /> ju M Do Not ill In <br /> WATER WELL DRILLERS REPORT State Well No Other <br /> Other Well No-----__---�-_ - _-- <br /> (Sections 787,1,7077,7078,Water Code) Region <br /> (1) Driller: l ` (2) Proposed use or uses (check): (3) Equipment used <br /> Name— �!___ ___ ____—_ Domestic � Municipal ❑ (check) <br /> ' Address----' V <br /> ---- ------- --- ------- Irngation ❑ Industrial ❑ Rotary ❑____-__�___ Domestic and Test well ❑ CableIncense No�u—s�-- - _.—Clasion____V_-. 7______ Irrigation ❑ Dug well ❑ <br /> Other----------- - —---—----------- Other-------- <br /> Owner. ,�—r �1' <br /> Name------l - -- r. r <br /> (4) Type of work check} <br /> Address— �_ _ _--__ New well Reconditioning of well ❑ <br /> l � ---------- Deepening existing well ❑ <br /> (5) Well log* <br /> Total depth of well__ 40_* ft Give details of formations penetrated, such as silt, peat, muck, sand, gravel, clay, shale, sand- <br /> Itone,hardpan, rock Include size of gravel (diameter) and sand (fine, medium, coarse), color <br /> Depth From Ground Surface of material, structure (loose,packed, cemented,soft,hard, brittle) <br /> __!J_ ft to__ <br /> - � <br /> ]l ff -,f <br /> _--______-- <br /> „ ,1 „ <br /> ff ff f] <br /> 1} 11 <br /> „ <br /> If additional space is required, continue on DWR Form No 246---Supplement, and attach to respective report copies <br /> (6) Casing left in well � <br /> c <br /> L£ DIAMETER <br /> FT BIN LE DOUBLE WELDED LBS PER FOOT OR SEATING BELOW <br />' FT IN,.!ES OTHER GAGE Or CASING GROUND SURFACE FT <br /> ------------ - ----- ----- - - -=------- ----- <br /> -- -- ---- ----- ------- _ <br /> -- _ -__--- --------- -'„--- ----- _--- ------ <br /> - - --------- --- - <br /> --- -- ------ --------------------- - ----- ---------------------- <br /> Type and size of shoe or well nn fiIelded joint es ❑ No <br /> D w R FORM No 246 REGIONAL WATER POLLUTION CONTROL BOARD COPY <br /> 23971 1 50 AOM VIN SPO <br />