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ORIGINAL WATER WELL DRILLERS REPbILT Da Not Fill 1n <br /> -t Pie Ortgnnat,baplltate and 7rnp11eale W111Y 15e (Sections 7076,7077,707X,W.t.r code) 1./, +,L. 10995 <br /> R$GIONAL WATER POLL ION - � `_- <br /> STATE OF CALIFORNIA StateWellNo..._— <br /> CONTROL $OARI) No �'X/ ls <br /> i �l(f.rnfepproprfeft naaibrr} OC1ttC�7ell N 7- #fin, <br /> 1) OWN�S 11) WELL LOG. <br /> Name J'CS a To-!depth fr Depch pf r�mpYretd weu l ft <br /> Address ? / , )otmacionx nrte,rb.f y ro7or,rfurererr.rru of w,.rrr,.r .nd rrrarfpre <br /> I #r t6 4Lfc <br /> oma Xi <br /> (2) LOCATION OF WELL: <br /> s -„ l 1 <br /> � <br /> own"'s otuohcr it ane--� <br /> IL F D or S «No + <br /> a <br /> ` J <br /> r <br /> 'I k j� OtD F7.7, el (2f <br /> (3) TYPE OF WORK (check) _ <br /> ^� New well I! -11, Deepening ❑ Rewndrttorang ❑ Abandon El <br /> S I f abarrdonmew,describe material and procedure In Year 11 <br /> (4) PROPOSED USE (check): (S) EQUIPMENT: <br /> Domestic industrial ❑ Municipal ❑ Rotary rt ,s <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ — — _t ` — <br /> Dug Well ❑ <br /> (5) CASING INSTALLED: If gravel packed <br /> SINGLE E?1DOU13LE❑ Gage <br /> or Ixy,oeter f from to <br /> Froml9f,s,R(oftt/4axt _Wall .ffMre � ,Er. ( <br /> t <br /> Type and 8.a of shoe or well ring Stns of grarelc <br /> Dtxx.[x jacat � <br /> (7) PERFORA NS: + <br /> Type of perforator oted <br /> Size of Perforations i. lm eh,b in. <br /> Fwa7a ft 14116 fr Puf per row rg21 llowe r ft- +. <br /> (&) CONSTRUCTION: <br /> Wsa a.urfaoe ranting ren!pronded? Mefe ❑NO To wiur deptk A/a f[, <br /> Vat nay strata reel d astin;t pollutma t HKCS [3mo If Teo,note depth of strata , <br /> Ftoltl qe,: it ro 7 fr ' <br /> Method of Sealing aro<lt started ,,�y, ,'�� f _completed �uJ,�� a <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> ' 'L This well was drttled under my jurfrdielron and!bs report it true to Ike beef of <br /> Depth at alttch war-w-firer fovad _ T 1, my knowledge and belief <br /> Standing YereY btfort perlorT4ag <br /> 19L <br /> NAME <br /> ORdleg heel afar Ptrforatmg o ft /YJ (Perermin 'SFrm✓yty pperrr-X,ilaai d <br /> p ir7pe or En,xud! <br /> Addrns <br /> 0 Z2&6&:5,-6, &,� <br /> (10) WELL TESTS: f <br /> Wa.a pump test madt? (D Yes lf'1Va f(7es,by wbprt? _ � ` a <br /> Yield �F�, gal fmtp with .r•� ft draw down&fur +—+ hew �SIGiVED]_, �� <br /> Temperature of water —�' Was a ch—ieal malyn.made? ❑ Yee �rll.dr Her <br /> f�Na Lcense No `'l _. Duel) ly <br /> Etat olecrru log mrde of well? n Yto 15,50 956e9 2 54 Soca QUIN Q sPo ! <br /> DWR FoRra Na 240 te¢v 9 Say <br />