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QUADRUPLICATE WATER WELL DRILLERS REPORT <br /> RETAIN THIS COPY h'4' (Section.7076,7077,7078,Water Gd.) N° 115949 ' <br /> Sla <br /> �f THE RESOURCES AGENCY OF CALIFORNIA Oche 'Welell l N <br /> ' Other Well No- <br /> Suf- ca a`n ct n »ipror�nleta�! rsfr�fci X39 . , <br /> OWNER: j (1 1) WELL LOG: <br /> + w�+ <br /> ",_Qarnle -cx*�-;:- (1 2eJ ,6 �S�Z�� Toe,l depth s{� 4t. Depth of completed well _ ft. <br /> Address Potmacionj Drrrribr by culor,rbararirr,jilt of-welrrial,sod slrwrtwrr. <br /> - - ft.to ft. - <br /> (2) LOCATION OF WELL: <br /> CAvnty S,.J , Owner's number,if ony—. ! ry"' 50 447. 2 '� -� Ar <br /> - <br /> A.F.D.or Street No.h,mfr p J / �,/ ,•.,•. S - - <br /> •(.l.11S .5=4.1 L 4. 5� riLC .r7�rt�.T(,1 Q! .a �j1L" •.M k J <br /> MW <br /> .(3) TYPE OF WORK (check): <br /> New well Deepening ❑ Reconditioning ❑ Abandon ❑ $" ia <br /> If abandonment-1 describe vnale-rial and procedure in hent 11.' <br /> l4iir <br /> (4) PROPOSED USE (check): (S) EQUIPMENT: " <br /> Domestic r�j Industrial ❑ Municipal © Rotary O e? IVOA <br /> Irrigation Test Well ❑ Other Cable <br /> Dug Well �I�e <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLE.J4-DOUBLE❑ - Gage <br /> +++���ii� Diameter from to or <br /> From ft,m ft. Dian.. wall - of Bore ft. it. _ <br /> Type and size of ahae or well ring 0. 5;..of gravel: <br /> Ducrebe joint <br /> (7) 'PERFORATIONS: <br /> Type of,perforator used <br /> SIZe 'of perforations in.,lonpih,by - in. <br /> Frglkl it.to ft. Pari.per row 0A. y 'Lowe per ft. „ <br /> (8) CONSTRUCTION: <br /> :,i-_ was s surface a¢itary anl_provided?. ❑ Yes ❑ No To'what depth fe_. <br /> Wert any scratt,saled againec pollutiori? ❑ Ycg ❑ No.-V.yes,note depth of strata <br /> . �From <br /> Method of Sealing. Wont at.rted 144' <br /> r,� Garnplemd i <br /> (9) WATER LEVELS: WELL DAILLER'S STATEMENT: ` <br /> This well Wsa drilled rtnder,ray j"risdirfion arse!ibis:rcporf is :enc to the'best=af <br /> Depth.r which.rater wrr 5rstJound � � ft, <br /> my Fnowledge at*e belief. <br /> Standing level before perfarasinp: - i°' NAME - -- <br /> ::ending Itrel after oeeforat?ng (Perron,5rm,or to+pocasion <br /> -- - - -- -- --- — �ar�•---' _ ) - (TYpad o-Pnrled) <br /> Address <br /> (1 a) WELL TESTS: <br /> Was a pump test made? ❑ Yes' [3 No If yes;by whom? <br /> Yield: geLlmin• with fr. draw down after hes. <br /> Temperarum of water Was -chemic-] ars-lyaia m-de? ❑ Yt, ❑ No <br /> License No. ��____._____ __ Dated�_.�_-__--- ___, 1q_�^_,_• <br /> We.eloctdc log m,de of well? [] Ye, ❑ No . <br /> A04 f <br />