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t <br /> ORIGINAL„ WATER. WELL DRILLERS REPORT Do Not Fill lay <br /> 1 File original,Duplicate and Triplicate with theNO 64359 <br /> 4 <br /> (Seehona 7076,7077,7078,Water Code) <br /> REGIONAL WA'T'ER POLLUTION <br /> i CONTROL BOARD No- STATE OF CALIFORNIA Saco Wal]No <br /> 'Tinct aper+priete+rmbrr) Other Well No _ <br /> OWNER• {11} WELL LOG: <br /> Name f' <br /> Total depth1111117 fr Depth of completed welE �� f <br /> Add I 3 Formation Derrrsbe by color ebar+tttr,laze of a+aftrW and drurtAra <br /> ft to ft <br /> (Z) LOCA'T'ION OF WELL, <br /> Cosily Owners lumber if any— <br /> Of Street Na <br /> (3) TYPE OF WORK (check) . <br /> lNew well 3 Deepening ❑ Reconditioning 0 Abandon ❑ ' <br /> 1f abandonment,describe maternal arad procedure m Item II _ <br /> (4) PROPOSED USE (check): (5) EQUIPMENToe de <br /> Domestic F1 Industrial ❑ Municipal ❑ Rotary Ix �.. <br /> Irngation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> AL, L4 <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE�& DOU$L E- .� Gabe <br /> ! or Dsameter from to <br /> From loft to Zftl/Jf�� ;mm / D Wall of Borr IT ft <br /> 01r <br /> Type sad au of shoe ar well ring a ea.elOn <br /> - <br /> Draerrbt <br /> (7) PERFORATIONS 01 <br /> Type of perforator vied <br /> Size of perferat <br /> as tea=�, b7 <br /> From £t to it Fe f per row Row,per It <br /> (8) CONSTRUCTION —. r.r.��rf r•r„l, ;t� �. , <br /> Was a sucrate saasrarr sell provided? <br /> Yes No To what Depth �• ft <br /> 'Gere nay strata sealed Igunsr possucxoa? Yea i] Na it yea note depth of sxrata <br /> .From /f 0 <br /> it <br /> Method of Sealm G ' <br /> Work starred 9 Camp[eted F9 1 <br /> (9) WATER LEVELS. WELL DRILLER'S STATEMENT <br /> Lt-gTbrs well uas dulled un u.lpdg�d beluf <br /> na der my lursidtetron and tbrs report true to the best of <br /> avej water war rrt ftwad aft y k <br /> d r <br /> amR vel before puforas,ngft UU u�(,19 f � �/o / �J (L <br /> 4aR feel afterft <br /> perforn,,x <br /> � �p-nc d-m e=ae _ - s eta• <br /> Address ,T n , <br /> (10) WELL TESTS. <br /> Was a P`mP tele made; ❑ Yes 0 No If 7an,by whom? <br /> Yseld gal/=a with 1t draw down after hn (.aIG NED)_,._ _ �A <br /> 1 // <br /> Tamperaxure of+taxer '(ria a chem,tel analyse made? ❑ Yea well firer <br /> I3(] pa — <br /> __ _ _ License No. _ ,. .. _ Dated- _ ...//// <br />