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4 <br /> 0r 1 [NAL WATER WELL DRILLERS REPORT Do Nat Ft1I In <br /> File Original,Duplicate and Triplitale with the (seecmns 7016,707r,7070,water Cad.) NO* <br /> MGIDNAL WAT$R I'OLLUTIOFi State Well <br /> • STATE OF CALIFORNIA <br /> CONTROL BOARD No � Other Weil <br /> Etrrra to r[sleresttnbn <br /> OWNER• fes, �see�i� (11) WELL LOG. <br /> r e <br /> Name T_o.sl dmth _. '7 ft Depth.(completed veil /•yC �+� _ - It <br /> AddressFormanoat Drsrrr&e by corer,charer,er,,Ire of ewlerfal,And r)tste,sre <br /> to ft <br /> A f r J7 <br /> (2) LOCATION OF WELL- <br /> Cottatyst,��1 t� ^r " r •� - owrter'r ,number,1f any- <br /> r <br /> R F D of Srreet• 0 1• <br /> �Qztb <br /> r <br /> a O w 1D 9 <br /> (3) TYPE OF WORK (Check) d ' <br /> New well M000, Deepeneng 0 Reeondicroneng Q Abandon <br /> If obm dannrersi,desMbe material and proatdisre In Iitm_ 11. _ r <br /> (4) PROPOSED USE (check). (5) EQUIPME196 <br /> Domestic ❑ Industrial [❑ Municipal [ Rotary • t d <br /> Irrlgatlon ElTest Well ❑ Other ❑ Cable [I , _ 1.`i. <br /> Du Well ❑ <br /> (6) CASING INSTALLED: If gravel packed <br /> SiNGLL+jfl DOUBLE i 7g <br /> Gage <br /> of Asameter £cora to <br /> From it . it I),= Wa11 of Sora ft it <br /> F/ 1 <br /> Type tad Mae of the.of veil ctax X2sue of gavel <br /> lh=nbajwse� <br /> (7) PERFORATIONS. -- <br /> 7ype of perforator vied , <br /> SIZe of aerfatadoto m,reaxth by Is <br /> From fr re !t Pet, per raw Row pet It + <br /> , . �,.ti_ •. � �� it <br /> (8) CONSTRUCTION: <br /> Was a rur(see ntnl USE ® 1�—Y raniuey sial prev,ded? ea ❑N. To whse depth /�\yt <br /> an <br /> _ L � _- <br /> Wert y suata sealed apaletae polnttoaT [ t. ❑Flo 1E yd.nate depth of rrrssa t�nn nrr_l <br /> �T�� , iT t <br /> IICOIII ft w Et � -- � — —- -- ,. �.. Y•� <br /> Method of Sealing mark uatted 7- - t9�� Comptestd / t� Iyer <br /> (9) WATER LEVELS. <br /> _ WELL DRILLER'S STATEMENT _ <br /> T'Ias well was ditlied under my;unedsvilan arid Ibis report is ftue to the ter£ of <br /> Depth at wbleh rater was Aust found &in fe_ any knowledge and beJref <br /> Srandenp level beton, "Joeetlog _ --- - - - - - - it NAME <br /> inx level after petforati'x it {Prssoa,Sint,or carotoua I I yyrd at ft+ rdj <br /> • ` _— _ —_� �.. __ Address 1- <br /> (10) WELL, TESTS: <br /> was a pump test made? [] Yet L]No if yes,by whom? <br /> YrEdel/ n with ft draw down after bre ESIGNED _ - - <br /> xcaa <br /> s _ _ _ p $r![Dtlrirr� <br /> Temperaeure of water ties a chemical sualims m1:,1ct:rlsE Ido <br /> ade? l3 Yes 11 No I I Y EJ ;e��- Dated— <br /> vu <br /> atcti <br /> __ <br /> Via electne lop,made of well! [] Yes y7q. <br /> 57aas 4-e7 eost vulY a apo DWR ]Go IRry 3 CRl <br />