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ORWWAL WATER WELL DRILLERS REPORT Do Not fill In <br /> Fite Orlgindl,Dliplieate and Triplicate SWilh lha (Sections 7016,torr,7078,Water Godo) © 14291 <br /> REGIONAL. WATER POLL(I�TON <br /> SnFie�Well <br /> CONTROL BOARD Nam-% _ STATE OF CALIFORNIA �~ Y <br /> (fasrrl epj•ro¢rtets-smart} CS[hee We11130. <br /> ` t) OWNER• (I I) WELL LOG: <br /> Name Total d h <br /> epi [_ It Deptit of completed Wdi <br /> Ad[9fes$ q!r) �r n Pte/ Formas7oa Dracrfbe i<r rotor,ebneeler,Iter of metniai and strarlvre <br /> _L-C 221 fe to r� <br /> (2) L CATION Of WELL: <br /> R F P <br /> PI <br /> (3) TYPE OF WORK (check): F� -" <br /> New well W/ Deepening ❑ Recondluornng ❑ Abandon ❑ " <br /> If abandonmeni,describe maleraal and procedure id Ileac II <br /> (4) PROPOSED USE, (check): (S) EQUIPMENT- <br /> Domestic ,'Udustrial ❑ Municipal ❑ Rotary ❑e� <br /> Irrigation ❑ Test Well El Other El Dug <br /> 11 " <br /> DUg Well ❑ <br /> f� (6) CASING INSTALLED- If gravel packed <br /> SINGLE LU-15'OUBLE Gabs , <br /> ar bianrtter�,rp iram <br /> From Ofato !( It4'etDlam. 1.z Vla11 of>lvre w ft eJ C fr <br /> , <br /> Tree seed nu of oboe or Will rata Sue of arasda '1 <br /> Dttertbe luras �j.0 �� Qin - <br /> Y <br /> (7) PERFORATIONS: <br /> Trp*of Per[oratoe WW , <br /> `yt <br /> SSZe of Iserfararlons in, leaArh br w <br /> From r tt en ft pecf per rgrr , Rews per it. „ <br /> (8) CONSTRUCTION. <br /> Was a surface sanitary seal pt"tdied? V1e7 El No To What depth tS �' is <br /> Wert am auaq reeled aaslaat potiation? ❑ , If ptl,note depth of strata .. <br /> From J n " — <br /> •ftb ft <br /> Method of Sealing �( "jr/ f Work erected /l am Q .1:4vCompined _'/ 1L.f f <br /> (9) WATER LEVELS: - ?; ? it- WELL DRILLER'S STATEMENT <br /> Tbh well was drilled tinder my jurisdiction and tau report is Irate to tba bell of <br /> DepiL at-Lath water Was first fovod }r � ft; t rosy,knowledge and belki <br /> staosl(ab I"before perferatlnb t' _aft ' i r f 0 e s <br /> _ ..inn terel after <br /> puCantins � � ,, q2.Y, f r�,l a (pertoa,Gtr,9r earperataon) ITYDed or Prsaerdl <br /> 7wprl <br /> Address (/ ���! <br /> (10) WELL TSPS. 1•} i t_ <br /> Was a Pwnp tett mode? ©Yes M'Dro If res.by W"t ' <br /> Yield �a sal fwo .sols -C~tea tr Ora.darn eater +�-�� hr� � Wil!Prtlrer <br /> We,Tsmpereosre vE Was— We,as a ehcmtcal--Ws model Nif <br /> ©Yes F]- " �Ce N0. . -_._._ <br /> _. - ------- - - ode? . 1 <br /> Wu electrk 10,aaade,f Weill ©YtlO <br /> on llie a SPO <br /> ��t� 536"3 Ga so <br /> ..-... .-.... Q DWR F(3RtA No 240 [HEV 3 54) <br />