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6:ar6lntar.' WATER WELL DRILLERS REPORT Do Not Fill In <br /> file-0111i Duplicate and Triplicate with the (Sereinas 7076,7977,7079,Water Cede) � <br /> - <br /> N9 96608 CUnQ <br /> REGIONAL WATER POLLi? <br /> CONTROL BOARD No N <br /> STATE OF CALIFO <br /> approprkrr t ']A7AE'w�t / Other Well NZ-0- <br /> OWN <br /> o OWI R� (11) WELL LOG: <br /> Name 4n Total depth 16 ft. Depth of completed well <br /> �.. ft. <br /> 4 <br /> Address Formuian: Dr;rrrbe by color, "Cr!",alae of •ter'i,eta slrnraurr. <br /> + <br /> Oft.to ft. -� <br /> f 6C/a <br /> (z) LOCATION PF WELL: "t <br /> County QQ�r'.number,if art — <br /> it.P.D.or street No- v� � <br /> 7F- all <br /> NF <br /> (3) TYPE OF WORK,(check): r <br /> New weft t Deepening ❑ Reconditioning ❑ Abandon ❑ (7 i <br /> If shandonmrnt,describe material and procedure in Item 11. <br />` (4) PROPOSED USE (check): (5)_ EQUIPMENT: <br /> Domestic industrial ❑ Municipal , Rotary 1Ab � <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable <br /> Dug Well ❑ G <br /> (6) CASJNG INSTALLED: If gravel packed <br /> SINGLE'M DOUBLE i 1 Gage <br /> From .01 -ay- Diameter from to " <br /> ft.to ft. Diem. Wall of Hore ft. ft. <br /> IF <br /> Type and size of that ar veil ri .e r Size at gravel: <br /> Da[ribe join[ Jill <br /> (7) PERFORATIONS: <br /> Type of perforator wed <br /> Size of perforations in.,length,by in. <br /> From ft.to ft. Perf.per row Row$par ft. •v <br /> (S) CONSTRUCTION: + As <br /> Wu a surfs".+Witney sett provided? No To what depth ft. <br /> 1�L :3J- ••�� -� <br /> iV1 <br /> Wen any strata sealed against pollution! 1 Ya ❑ No if yes,note depth of mats. . <br /> From ft.to U ft. t <br /> Method of Sealing /,2, C-pi _– – S,f 10, <br /> 'Work stated 19 Completed <br /> .�: 19 <br /> (9) WATER LEVELS: -.,� y WELL DRIL R'S STATEMENT: <br /> Depth as whiter carer was fiat found ft.. r <br /> This <br /> well was drilled under my jurisdiction and this rrper,is true to the best of <br /> my knouledgt acid belief. <br /> Sraad inn lcvrl before perforating ft. NAME <br /> ft. <br /> g lend"after perforuiag T`+:; <br /> AddressEAST REMONT STREET <br /> (10).•WELL TESTS: i : ... L.IFORNIA <br /> ti sT0 KT 5. <br /> a pttmp tart made! ❑ Yet Ne if yea,by whom? <br /> Yield <br /> gal./thin.-with 1t.draw doxy[fur lips. - <br /> IiIll Ar!lJrr _` <br /> Tamperaenre of carer 19u a chemical analysis made? ❑Per iy r; <br /> License Na --- •---•--•--. Dacrd._....�_ <br /> 'War,91 ing te,ade of wtllI ❑ Yea <br />