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#- ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File Original,Duplicate and Triplicate with the (sections 7076,7077,7071,Wat4r code) N? 67179 <br /> REGIONAL WATER POLLUTION <br /> STATE OF CALIFORNIA �, vJ ScatcWell Na.__.�I�.--�`. <br /> `'ONTROL BOARD No 1� <br /> i t � <br /> •rrrt epproprlale number) <br /> OWNER: (11) WELL LOG: !� <br /> V Name Tutal depth iO ft. Depth of complrred weal <br /> Address Formation: Drrcribr by rotor,cbaracter,mr of material,and structure. <br /> ft, to ft. <br /> IL <br /> Lee (?} <br /> LOCATION <br /> OF WEL � <br /> C�un[r r Owner's number,if any re <br /> — <br /> Irz <br /> R.F.D.orst'er;1 � � .' �� • <br /> Z 47 <br /> ds, <br /> (3) TYPE OF WORK (check); " <br /> New well X Deepening ❑ Reconditioning ❑ Ab2n4on ❑ <br /> If abandonment,describe material and procedure in Item I1. <br /> (4) P7P9S USE (check): (5) EQUIPMENT: <br /> Domestic Vndustrial ❑ Municipal ❑ Rotary <br /> Irrigation Test Well ❑ Other ❑ <br /> Cable <br /> ❑❑ <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLE DOUBLE Gap <br /> i]irmeter f:am to <br /> From p (a fc.�7d of <br /> Diam, Wal] of Bare ft. ft. •, <br /> �+ Type rnd s—of shoe at well ring Size of Err rel: . <br /> Dncnhe ions �l •• <br /> (7) PERFORATIONS: <br /> Type of perforate•need •• <br /> Size of oerforariooe in_,EenRth,by in. <br /> From ft. Prrf,per ra r Row,per fr. <br /> (8) CONSTRUCTION: <br /> Was a surface nninrr gyral pro•idedi' ❑ Yes El No To what depth it. ,• _ - <br /> Wrs any suaca sealed aaaiesc pollutiao? ® Yn ❑ No [f yo,noro depth of rtnta .. <br /> From ft.to 6 ft. " <br /> 1iie 1'Fethod of Sealing Work started !�� 19�` Camp3etcd <br /> (9) WATER LEVELS: WELL DRILLER'S STATE.rENT: <br /> This well was drilled ander my iurisdiction and this report is true to the best o. <br /> 4.2 Drprh at.hich wr_rr xv first feved ft• my know1ledge d belief. <br /> _ ndio�t lcrel 6efate perforacins ri l �^ l ^ <br /> ft' NA�£E( L lJ <br /> ' � tier Inc!if[e!peTSOAnnx ft. 1 Pcr ,arm,or corporauon �! � 'ype e <br /> Address <br /> ' t <br /> 46 (1 a) WELL TESTS: <br /> We.a pump cert made) 0 Yet ❑ No If yet,by whom? <br /> Yi0d: Irak-/saio. rith ft.dn.dovo after hra, l l DrfNfr <br /> Err Teropenturr of water Vas a chemical analysis made? ❑ Yea ❑ No License No---------------- - __ Dated___ -------------------------- <br /> c <br /> ----.--.---_.- -electric Ing made of well? ❑ Yet ❑ No <br /> 31025 a-ay POM QUIN tL spa DWR 188 (REV.3.aR) <br />