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Mar' 05 07 01:10p NCYC PLRNT OPS 209 948 0824 p.5 <br />STATE OF CALIFORNIA <br />DEPARTMENT OF HEALTH SERVICES <br />PUPLIC WATER SUPPLY BPJANCH <br />w <br />DA� <br />(1) Place and Owner: N <br />(2) Source of Infoxnation: F-L1e Date: <br />Collected by: <br />1 _ 1 <br />(3) <br />Number or Name. _ <br />Date Drilled . . <br />(4) <br />Location: <br />} l <br />Neighborhood . - - - i <br />Size of Lot - <br />D7.starsce to: Sewer i <br />I <br />Sewage Disposal <br />} 1 <br />Abandoned well - <br />I <br />Nearest prop- Line. <br />I 1 <br />Hours ing : Type { <br />R <br />Condition . . . . . • { <br />I <br />Pit Depth (if any)- { <br />ne <br />I <br />Floor (material.) <br />Drainage. <br />(6) <br />Well Depth . . I <br />3' } } <br />(7) <br />Casing: Depth. - .. I <br />{ <br />! <br />16" <br />Diameter. . . . . . . <br />j <br />Sa: <br />Rind . . . . . . . . <br />" 4 I <br />Tight. above_ floor . . 'r20 <br />Dint, to highest perf. <br />124 I <br />Sur -ace sealed (yes/no)] <br />Yr - <br />Gra --rel pack (Yes/no) I <br />G 1 <br />2nd casing depth. i <br />2nd casing' diameter. f <br />,r <br />2 <br />Annular sea! (depth) <br />{ <br />(8) <br />imperV . strata Penetrated i <br />Thickness. . . . . . . i. <br />Depth to . . . . . . . ) <br />1 I i <br />(g) <br />Water Levels -Depth to: I <br />Surface. I <br />N h <br />Static . . . . . . . . { <br />43. } �. <br />When pumping I <br />104.0 <br />(10) <br />pump: Make ) <br />Flowv <br />Type . . . . . . . . . <br />Turbines <br />Capacity, gpm- <br />141 <br />cationi-. <br />Water _ <br />. <br />440 <br />Lubri <br />Auxiliary' Power. I <br />None <br />Control- .i <br />Tnnk Level St <br />Discharge Location IAbo <br />'f':snks 4 <br />Discharge to .. _ . . . 1 „� <br />(11) <br />Frequency of Use. i <br />W <br />I? i wh( <br />Minimal <br />(12) <br />Flood Hazard. . . . . . i <br />i <br />(13) <br />Remarks & Defects <br />Crackcd wc11 case at 136 foot depth <br />(can -use other side) <br />i <br />