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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fsll In <br /> File Orlglna1.Dllpilcate and Triplicate with the (sections 7076,7077,yon,'rater Code) No 94068 <br /> REGIONAL WATER POLLUTION cii P1%State el!No" 17 '7c=) <br /> CONTROL BOARD No- <br /> 0-- <br /> STATE OF CALIFORNIA <br /> '?"seri e¢proprfatr aansberj Other Well No._ _ <br /> . t I) OWNER (11) WELL LOG. <br /> Name ' Total depth it Depth of completed well f <br /> Address 2 Formation Drscnbr by Color,ch"artn,iia of material and stricture <br /> it to it <br /> (2) LO TION OF W3LL• <br /> Couatl er i naps r sf any— <br /> R F D Street No <br /> 'yU <br /> 'W <br /> Rt <br /> gNew(3) TYPE OF WORK (check). )77 -zip- <br /> New <br /> Well x Deepentssg ❑ Retondatiomng ❑ Abandon ❑ 9W 47 ^� <br /> If abandonment,describe material and procedure in Item II ;ct <br /> (4) PROPOSED USE (check). (5) ,EQUIPMENT: <br /> Domestic ❑ Industrial ❑ Municipal ❑ Rotary <br /> Irrigation X Test Well EDOther ❑ Cable <br /> Dug Well VAdo z, <br /> (6) CASING INSTALLED If gravel packed AZ <br /> 3 <br /> SINGLE DOUBLE ❑ G■Se <br /> of Diameter from to <br /> From ft to it Diam wall of Sore ft it <br /> .07 <br /> Type tad size of shoe or well nn Size of gravel <br /> Describe point <br /> (7) PERFORATIONS <br /> Type of perforate-„..od <br /> SIZC of perforations in lesigth by is <br /> Fnxn it m it Perf per row Row.per Is <br /> B <br /> (8) CONSTRUCTION: <br /> -� <br /> Was a surface sapstary sea]provided? ❑ Yes ❑ No To what depth it -•• - -s <br /> Were any strata sealed*Swwt pollution? ❑ Yin ❑ No If ye.,note depth of strata •ti <br /> From it to it <br /> Method of Sealing Work started 19,4,7 Completed 19 2 <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> Ther well was drilled artier my jurisdiction and ihts report is true to the best of <br /> Depth at which water was lint found It my knowledge and belief <br /> Standiag level before perfaratsns it NAME .j� ^ /f <br /> ding level after perforating / it (Person firm or corpt.r tion) ITyprd or pr sed? <br /> ! Address <br /> (i 0) WELL TESTS: <br /> War a pump tort made? ❑ Yes ❑ No If Too,by whom? —. <br /> Ysdd hit [SIGNEE — — -- — _— — <br /> gal Issue with ft draw down after bell DrtNn <br /> Temperature of water Was a ehemsnl malyns made? ❑ Ye. ❑ No License NO.. L—�`�`” � Dated- <br /> W.. <br /> -Y�� <br /> W..electric lag mads,of won? ❑ Yea ❑ No <br /> 57025 9 87 Cow 42UIN A aro DWR 188 (REV 3 341 <br />