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3>--- <br /> ppRIGINAI. WATER WELL DRILLERS REPORT I)&Not Fill In <br /> I71a OrIglllal,Dupfitals and Trlplleale wNh She Iseeeiame 7076,7077.7076,Water Q �Toda) ,�y .? 96632 <br /> REGIONAL WATER POLLUTION <br /> STATE 0>= CALIFORNIA Sure VdlRTa _� <br /> t <br /> CONTROL BOARD No j pharWoRNq�'� <br /> p!rlrlaiatsaobrrl <br /> OWNER. (11) WELL <br /> NaineTmaE depth fr eh of eesapledd*All <br /> Addrera Form■ttantDarnlbrbyoolor,rbveeter.Stu01 <br /> Asst >1 lrlraehsrt <br /> fr ra rt <br /> (2) LO ATTON OF WELL. <br /> Ovrar'e number.IF sqt-- <br /> 1[ F D ge 9tree- <br /> a <br /> (3) TYPE OF WORK (check): <br /> N.', m]+� Duperdnii El Reccadttwning ❑ Abondan © ' <br /> If abmd"ornt,descHbe-materrd and procedure to Rem 11. " <br /> (4) PROPOSED USE (check): (S) EQUIPMENT. ' <br /> Domestic"�dustnal ❑ Municipal ❑ Rotary y <br /> Irrigation q Teat Well ❑ Other ❑ Ca l Well <br /> Dug ❑ <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLE Nr DOu$l..E 0 <br /> Eisametat r to <br /> Itl'Oi71t'}k to �r'4__�Et_�; �a f of Bon r #; <br /> Type and are of shoo err well rms Sat of srawit <br /> DenriL■joint Ng Ma c f .. <br /> (7) PERFORATIONS: <br /> Type of perranter,titd . <br /> Sever of perfonnans X.lanitch.br in. ., <br /> From it to rt pai par sew dawn per ft <br /> (a) CONSTRUCTION: <br /> To a surfac■sanitary real prmtd■dl drYu Q No To what dept6 ft t.li t <br /> Wein any atne■"Rd salols polluttaa? 0 Ya ❑ No if res.not■depth of-tris■ .. � <br /> FrGM <br /> O rt to /.O <br /> Method of SCAM 4 Work a cedi Completed i <br /> (9) WATER LEVELS: � 'WELL DRILLEkS STATEMENT: <br /> This wX cues droUtd ander my rurhifirflan and toss rtporf a rrur to the bete of <br /> Depth sit vh Wt vicar van Ssre foxed fr. rnyl#vavkd$t mdd rbet �? <br /> dawn kick befata perfarattes IT NAME _ tTER �t• N ufl AC K `�R <br /> t SON, INC, <br />` <br /> 4411t=U-M alurpeetanna: .__.— ...rt I%-NyC�U,Ee {rrsFs 2ENi0 b .d�ltu relJ <br /> Addrear <br /> (14) WELL TESTS: <br /> was*pump sue rude? Q Ya - If yes by vlaaal <br /> Y*4141 ti I/satin lt - --- _ --- It draw down anter <br /> _ Wr rllrer/ /' <br /> Tempusttua of v■ter Wes a Aearisal anal7da made) (]Yet 7e I1Cdlsk N g. t t �r�f T r 19� <br /> Vu Actrm Ion made of vel]? a Yes Tio ' • " <br /> nms a-s?som Qum A apo DWR 186 IApV 8 841 <br />