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Lile <br /> ORIGINAL WATER WELL DRILLERS REPORT �T Do Not Fill In <br /> FOriginal,Duplicate and Triplicate with the STATE OF CALIFORNIA(secti.m 7076,7077,Tort,W=ter cod.) tell? 67179 <br /> REGIONAL WATER POLLUTION �� State Well No.—W-63T-�..�....---._ <br /> _ <br /> CONTROL BOARD No ` / Othcr VVdI N..---.......- <br /> -Irstrrt appropriate Wernher) � / -------- <br /> } OWNER: (11) WELL LOG: <br /> *me Total d pcii �0 ft. Depth of compicted well --- <br /> ddres �sr - Format,oa: Llnnib by color,rhararter,ri=e of metrial,and[tructurr. <br /> ft.To ft. <br /> J~ LL <br /> I. Y �2.-✓+r. <br /> (2) LOCATION OF WELL. I � / .----------•- <br /> County Ow•ntr's¢umber,if any- ! <br /> R.F.D.or 1";/" <br /> n -17 <br /> ti t �• s` fee <br /> TYPE OF WORK <br /> 9 'Yeu'a dl Deepening 7-] Reconditioning ❑ Ab�edon - <br /> It abandornncni,describe material and procedure in Item 11. <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> ' Dornestic .9 Industrial r Municipal L--; Rotary <br /> i. Irrigation 71Tesr Well .7' Other 1 bl <br /> L Dug -t ell <br /> t .. .. <br /> is (6) CASING INSTALLED: :f gravel packed <br /> SINGLE DOUBLE Gaet • <br /> / Diamcre: from <br /> From c : .:r fC r:.��� _��Il o:Lore <br /> � {II <br /> '.Typ,and site of shw-e <br /> oe o li—ZI Size of Gravel: <br /> a .. .L . <br /> Dr, vibe joint ;�. - •• •_ <br /> L (7) PERFORATIONS: <br /> € <br /> Type of ptrforato-used ,. <br /> SIZE of perfo:ationa ,o.,ieorth,by <br /> From f,.,. ft. perf.per ran Rcz•.per lei. <br /> . .. <br /> 111 .. .. .. <br /> (8) CONSTRUCTION:L <br /> was a rurfaee""tar"teal prodded? ❑ Yu ❑ No To whu depth ft. <br /> Were any..rata sealed ggaiar=pollution? ® Yu 0 No If yo,note depth of strata .. .. <br /> From 0 rt.to 6 ft. <br /> Method of Sealing wont starred _ �– 1911,/ Completed <br /> {9) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> This well war drilled under my jurisdiction and this report is true to the best of <br /> ��Deprh aT which water war first found - ft• My knowI dge db IF f_ <br /> 1i� <br /> +' Staadseg I,.el before perforatinG f[. 'tf <br /> !ing Ierd after perforating ft. {per. erm,or eorp4ra c;yn 1 'ypr r <br /> L <br /> Address - <br /> 7) '1VELL TESTS: <br /> a•o a pump test made? ❑ To ❑ No If To,br whom? <br /> L <br /> Y;dd: gal.b io.with it,drat.doer after hra SIGNET) __ <br /> ?r Driurr <br /> Teeoperatur,of watsr lrsic made? ❑ Yo [] No License No..-___-__-_-----�_.__. <br /> --------. Dated-----------'------------------------r 19---------V-a!eircrxic log mad,of wAlT ❑ Yes 0 Ne <br />