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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill Im <br /> File Original,Ouplieate and Triplicate with Ilia (seattotta 7076,yon,)1078,mater Cade) No qty <br /> REGIONAL WATER POLLUTION w .. 1 <br /> STATE OF CALIFORNIA state Welt No <br /> CONTROL BOARS No �*r'1 <br /> -t appromaie■umber) • Other Well No.— _ <br /> t i/ OWNED {1 1) WELL LOG,Z" / <br /> Name Total depth / it Depth of conaplcted well G <br /> -- - r* ri-+ ft <br /> Addre Formauan Des-1ja by rola, rbararen uzr o/masrrml and s&vctnr, <br /> it to it <br /> ea <br /> L ATI N OF WELL: <br /> Counn per a number If any_... i <br /> R P D or Strea <br /> IF <br /> (3) TYPE OF WORK (check): <br /> Q <br /> Ne-*elJX Deepening Q Reconditioning [I Abandon ❑ <br /> Il abandonment,descrrbe material and procedure sn item I1 <br /> (4) PROPOSED USE (check) (5) EQUIPMENT- <br /> Domestic,X Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable X 1,09 <br /> Dug Well ❑ ly I'D 41 to <br /> (6) CASING INSTALLED If gravel packed <br /> SINGL.E,k DOUBLE—11 Gale <br /> or DIAZ- f oro ea <br /> From tt in it DuEn Wall of Bare it ft <br /> JV <br /> Z <br /> 01 <br /> Tvpe and n,e of shoe ar veil ,ng Sue of Gravel <br /> a?cserc6e�oiot - <br /> (?) PERFORATIONS. <br /> Type of perforate,aced � <br /> size of"eforanons m Ienath 6y ca <br /> From Ir tn ft Perf per row Rows per it <br /> 8 <br /> (s) CONSTRUCTION. 3 <br /> Was a sur ue saauearr cell proecded? XYer Q No To what depthft -- - - USE <br /> �St irl s tuttlL ' <br /> Were any strap sealed against pollution s Cl Yea © No If To note depth of strata <br /> From Ct ce it <br /> Method of Sealing Work started 19 Completed I9 <br /> (9) WATER LEVELS: WELL DRILLER'S STATEIMENT <br /> This well was drilled under my )ar:sdretion and thy.; report is true to the best 4q <br /> Depth at vhsch water was first found it my knowledge and belief <br /> i <br /> dcuR leral before perforadas ft <br /> NAME si i . .I! a r ,t i ` v .Z, <br /> ' JsaR lerel aftu perforaegR fc �• <br /> i ,sari M r c ct�i,_ 7yth$ s+ <br /> (1 a) WELL TESTS: <br /> V7a.a pump use made? Q Yet 0 N?o If yes.by whom? <br /> Yield Rai/min arab it draw down after bra (SIGNED] r - <br /> Temperature of waren Wan a ehemanI analysis mads? ❑ Yea ❑ Na <br /> License No <br />