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IL ORIGINAL CATER WELL DRILLERS REPuRT Do Not Fill In
<br /> r File Original,Duplicate and Triplicate with the (sectiaos 7076, 7077,7078, Worse code) lr�T 9 56570
<br /> i. REGIONAL WATER POLLUTION S:a[e Well No.__ _trot
<br /> STATE OF CALIFORNIA 23J CONTROL BOARD No, p -� / Other Well No..- 1I1/6E
<br /> _:>1 Otaste.pp.oprmer..mberJ - _ .
<br /> ... toot..
<br /> ;l t) OWNER: (11) WELL LOG:
<br /> Name �„ ._✓ % Lf _ Ta.a� d<rrh fJG r"'Is of ...plead .test ft.
<br /> 1 Address . ( 7 _ l<,:-e_. Formarit „ am rr.Drr,be by r th. ,,i.r ofm.ar.,d,... , r.r?,.,r.
<br /> 1 "r ft , t fr �a urc
<br /> (2) LOCATION OF WELL" -
<br /> oaorrspoub,✓/ faoy— L f
<br /> R. F. D. 5 reef No S.� f 777/: n� -_ L .- G
<br /> hl
<br /> (3) TYPE OF WORK (check) :
<br /> �....1 New well � Deepening ❑ Reconditioning ❑ Abandon ❑
<br /> ._) if abandonment,deuiibe mo1es1ol and procedure in 1fem 17.
<br /> (4) PROPOSED USE (check) : (5) EQUIPMENT: zV, Iy,5 � .• �yC, 7
<br /> Domestic Z Industrial El Municipal ❑ Rotary 2 ltt-i /ate
<br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑
<br /> Dug Well ❑
<br /> (6) CASING INSTALLED: If gravel packed —
<br /> SINGLE 21 DOUBLE _ Gage ,t. -- - ----- —
<br /> Dia,neter from _
<br /> From Cr fro '. 7.7 f rn of e.rr Is. n.
<br /> r1 _
<br /> Pyre and r . of,h.,or writ n.e ' 51x .f.crave): ..
<br /> Dmrribe:tits �� � -
<br /> i
<br /> j: 1 (7) PERFORATIONS: . —
<br /> Typr of pe,for2em mod .. ..
<br /> Size of pert..... ..t I..B,h, by .. ..
<br /> IFrom (e, to ft. ,Pert. per row R,-+., per is. .. ..
<br /> (8) CONSTRUCTION:
<br /> War r turfs. mnimq nal pn eid,d? ❑ Yet ❑ No To wh., depth is.
<br /> —' Wer<a.y nnv coaled a8aiasr patI.6. ? .z Yet ❑ No If Yer, nose deprh ofares,.
<br /> ..
<br /> From ft to
<br /> ' ..i Method of Sealing r _ .. Work...sted .. .. )s.. cbmrlrrra ly
<br /> (9) WATER LEVELS:
<br /> WELL DRILLER'S STATEMENT:
<br /> This well u'at drilled under my jurisdiction and this repast it true to the best of
<br /> JDrP,h or which wars,oar first food it. my knowledge/cord belief. -I
<br /> Sn.dl.g lrr,l before pedorad.g ft. NAMEI "iA>✓� ` /r� st1'I Ii L� l r-,, I/ f•..
<br /> ins level after p<rfor.a.,
<br /> i Address . ���! / i/ 'r -✓
<br /> (10) WELL TESTS:
<br /> j War a pomp test made? ❑ Yes ❑ No If yet,by whom? }
<br /> [SIGNED] - / .> _
<br /> Yield: 8d./mist with [.. dr.. down after hrr . ._.___..-..._...-. .. �,.eL�__ nv:�... .____.-------
<br /> :- i �iVrll Drilfrr
<br /> Teamsters—of water War a chemical ..],is made? ❑ Yes ❑ No License No.---.---..-._..._-__._-_.__...... Dated...._-...___-__._____-_
<br /> Was elee,ne I.,mode of well? 0 Y,r ❑ N.
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