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ORMINAL WATER WELL DPJLURS REPORT Do Not Fill In <br /> File Womal Uuplusfe and Trfplieafe wlib the ($4000.e 707d,7077,7472,W.t r e.&) N9 67179 <br /> 9 <br /> MG10Ma WATM PaLLUTZpN Scatc W ell Nv �- � R I <br /> STATE OF CALIFORNIAf� y <br /> CONTROL BOARD l�io� — �'" �r7set�allNa ��� �,,�.'•, <br /> i ) OWNER: (11) 1VPaL,L LOG: <br /> Name24t,�V_ :.w AWA ♦ tr. eao+sleeed Wrdr �'� tt <br /> I Address J— Forms"Ma IMatraw,by color,rb,..rpr,scar f aa./rrfel ami som"mr. <br /> 1 O tow is <br /> .7- Ila. ' <br /> (2) LOCATION OF " <br />' Cuvaa Oweer a q-mbrr,It <br /> ML F.11 era N <br />' (3) 'TYPE OF WORK (check) <br /> Nen W1 0 Daepemo9 l3 Rec"twalax ❑ A.boodaM ❑ <br /> if ebardor►mrrlt,dAcr36r,rrstrrid mrd proe dstre in horn 1 f. ' <br /> (4) PROPOSED ME (check): (3) EQUIPMENT: " <br />' Domestic 03 InduaLcl21 ❑ Municipal ❑ Rotary Q » <br /> Trngation ❑ TcstWell C] Other 0 cable <br /> eDug Well ❑ .. <br />' (6) CASING INSTALLED- If gravel packed " <br /> SkN13t.1:® DOUBLE❑ Gs:. <br /> / oe Illas.d� frac to <br /> From O f.w fP f, orl Mam. Va11 of 1300 fr. it » <br /> 7Yps eod 0070 of do*ar well naeS.ae a1 s"r.l <br /> Detorlb.roue .. » � <br /> I (7) PERFORATION& » <br /> Type d serfonto+wed <br /> Size of sat#aat5.ea In..LOURrh,b <br />' From Ir to it Pert ser row Xa .Pe it- <br /> (8) <br /> t(S) CONSTRU(MON: <br /> V.a a amf.p amitur real pmrldedl ❑Yea E31b To what depth it » py[ <br />' Wen aFY artata«old apaart poloelm} Q Yea Q No n - - � - � i 1 j •-_. — <br /> / pa,p.q de7}rh of atrsta <br /> Frear! [r r. b to •• <br />' Method of Seahn - _ _ liwk--wad e / camybud �. 1 <br /> (9) WATPA LEVELS: VSU DRI X.LER'S STATEMMiT <br /> Thk t a ow drfoed ander mfr fartrdfcdon,tad 06 n*rt u Am 10 t w bost of <br />' flepeh at*Binh�Zur vn Sm Emma l*- ftyjdlllidoe �f rf. <br /> andioi Seri helot.yatorseraa fr T$/4MH <br /> bar Ln1 after garlocatio= fi l firm.w torpasa4ow S v <br /> Addrrss <br />' (1 o) VEI.Ia TPSTS: <br /> v.e s semp an ma&? 0 Yrr A No If rw4 by wWm? <br /> y1adt pl./aaf4.With 1.in.dow.slur las l 3"Y `� Driller <br /> Tclpgntor.o[.n,�a war a a.231.1 a147a.ea2&7 ❑Yea 11 Ne 13Cerale Ha I]1<tet�_... _may I9 <br />' <br /> VAS tlertrie Itis msda.dvdt? ❑To CI N. <br /> sao.s 6 37 awt nuts p aro r- GWR 1BB IRZtf• ssl <br />