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t,3ifr� t I:]N ?ICT Cl-H (;�� <br /> I.ORIGINAL: WATER WELL DRILLERS REPORT Do Not ,Fill 1R <br /> File Original,Daplieale and Triplicate with the (Section$7076,7077,7071,{hater code) N9 96615 <br /> REGIONAL WATER POLLU N � <br /> CONTROL BOARD Na STATE OF CALIF. RN1A .� Suu Well No ........ .......... <br /> ..... <br /> . .-........ . <br /> t epPbPn•tr u.�bsrj w ,4 <br /> other'Wen N�- <br /> OWNER: (11) WELL LOG: <br /> Name Gt l dG a Totar / <br /> depth ft. Depth of[.in <br /> plctcd -C)l J ft. <br /> Address9 CIA If Formation: Deimbr by color,rber$rt*r,rise of a it"ii 1,and rtrvelvrc <br /> ft.To <br /> y. <br /> (2.)�LOCAT�ON OF WELL: <br /> C4 r? I< rA Owner's number•if any-- C <br /> R.P,D.or Street No, r <br /> " .. <br /> C G <br /> (3) TYPE OF 'WORK (check).- <br /> New <br /> check):New well� Deepening [1 Reconditioning 0 Abandon E] �+ <br /> 1 f abandonment,describe material and procedure in Item 11. r' i <br /> (4) PROPOSED USE (check): (5)' EQUIPMENT: <br /> Domestic ,Industrial ❑, Municipal ❑ Rotary � <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable <br /> Dug Well ❑ / �� — <br /> c <br /> (6) CASING INSTALLED: If gravel packed b O <br /> SINGLE X C)OLSBLE i, Gage ' <br /> Diameter from to C� <br /> of Sore ft. <br /> FrOrrl©fx.to ft. Diem. <br /> El Z <br /> Type end size of shoe or well ring Size of gravel: , <br /> Ductibe joint •• <br /> (7) PERFORATIONS: <br /> Type of perfoutor teed •• <br /> Size of perforations in. enxth,by <br /> Froyn ft.t. ft, orf.per row Rows per it. ------------------------- <br /> .. .. <br /> r r <br /> 1 <br /> (8) CONSTRUCTION: - <br /> War a surface unitary seal provided? es '• _ Y`a <br /> �S t'� No To whit depth ft. ,•-•'.•.• —_ '--""+-. <br /> Were any strata reeled against pollution? OtlYea ❑ No If ya,nose depot of strata <br /> From ft,to ft <br /> Method of Sealiflg a 5c y <br /> Work started' 19 Completed / <br /> 19 <br /> (9) WATER LEVELS: WELL DRILL R'S STATEMENT: <br /> Depth at which water was 6r.e feond6 Tbit well wa drilled under my jurirdieti n d Dear rrfiort ' true to the beat of <br /> my keeo-? a be <br /> e'^ding level before perforating ft. <br /> x lose?after pufontiax ' ' <br /> NAME <br /> ft. (Person. or cor twee) 0 or iwed) <br /> 1564, <br /> (10) WELL TESTS: Addrqa <br /> Wu a pump test made? ❑ Yea KNo If Yee,by wham? -. <br /> Yield? ..„. <br /> xal•/talc. with :-, ft.drew dawn ofmr -.._.------- <br /> Temperacu a of voter Wee a dhemipl analyda mtae? Det <br /> ads? ❑ Yet IVa" <br /> License No / <br /> _ -- - <br /> nPas electric log mDated_ <br /> Trade of well? ❑ Yea �No 19 <br /> "V2116-57 Dots QUIN Q aro OWR 11313 ?Rev. s,sn <br />