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APR 7 1966 <br /> useORIGINAL WATER WELL DRILLERS RE ORT Do Not <br /> Fill In <br /> File Original,Duplicate and Triplicate with the If aeetioa.1016,7077,7072,Water Code) N4 1 8 Q 5 7 <br /> REGIONAL WATER POLLUTION /�06 State Well .No— <br /> STATE _ <br /> STATE OF CALIFORNIA --'-' <br /> CONTROL BOARD No y � C <br /> •aelreerl.n cumber) - JS Other Well No.03t��de„- <br /> (1) O ^R: (11) WELL LOG: <br /> r Name l4 z .-IaTn,.l d<p,h l 2 D ft. Dev,h oI<omdn<a hell <br /> Address g Formuion: Dnnrbr by rola,rbmrrn,nsr at <br /> 1 G M a re.n ) p <br /> (2) LOCATION OF WELL: a44 �!I <br /> VI .. / lI <br /> R.F.D.or Srt<n No. y <br /> ` t' 16 a <br /> o3R/�6E ro it <br /> - Ume <br /> (3) TYPE OF WORK (check): (� 1,711 <br /> New wellJoDeepening ❑ Reconditioning ❑ Abandon 13 ` <br /> e. <br /> if abandonment,describe material and procedure in Item 11. / h /i <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: u <br /> Domestic [ Industrial ❑ Municipal ❑ Rocary q .. �+7 / <br /> .. Irrigation F-1Test Well ❑ Other 1-1Cable [� 1.2 B t <br /> Dug Well [[JJ <br /> (6) CA./SING INSTALLED: If gravel packed <br /> SINGLE lad DOUBLE L Gem lli.maer f.em to <br /> From I,.n f,. Di... q W.11 of Bon ft. it. „ <br /> r., <br /> T>p end rias of aha or rdl era Size of Reel: .. .. <br /> Describe Its., 11 <br /> [[ .. .. <br /> (7) PERFORATIONS: <br /> Type Pnrenem a.ed <br /> S12G o/perfwnirm <br /> FrOm 6.m f,. Pert pe.r.. <br /> 1 1 <br /> (8) CONSTRUCTION: .. ,. <br /> ` Wu...,free u.i,.,eel Presided? ❑ Ye. IN. Te.h„d,,h is. •, <br /> rare..>777777 tested q.irn Irolleeioe) ❑ Y. �"e If Yn,rote d.,,h of....77 .. .. <br /> From it.n n. .. .. <br /> Method of Sealing u di/ Work rt.t,ea — ( ,y r- .. a (, C—,I.,.d I—=-- <br /> (9) <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> /--- This tuell Laos drilled undn my ju hericlion and tbis rrporf is true to the best of <br /> u.. card.,%,huh vests,.n fir,,fated 9 It. my knowled en/d/btlirnf. /� <br /> Miq inti before P.fomie2 fa NAME ( D I/1/ �ll ,f/-( <br /> I:aa loel sker perfomira L f+. r� P n,br a •nuuun 1 spd w p vNl <br /> (10) WELL TESTS: C' <br /> Va..Peter rare..ties ❑ Yn 4No If yet,by.l,om i <br /> Yield, nl./.:r. deh it.dna dose der hn. <br /> — Tampnewe el.un w..chemial.erl.d,..d0 [:] 9 L2 T. ❑ Ne License Naar. ..:D. �� Dated. _.._................. <br /> V.,.Lcnfc toe.rd,of.ell? 0 Y. 36 Ne <br />