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MOT CHECKED <br /> LOCAI ION 'i <br /> 134fGINAL STA'I'D OF CALIFORNIA SHEET 1 <br /> File Ortglail,Duplicate and Triplicate MIN the DEFARTMENT OF PUBLI "tM<5` <br /> DIVISION OF V44YER RESOURCES <br /> P P SOX 5079 IVIAN OF WATER 39`433 <br /> SACRAMENTO 5 CALIFORNIA `� <br /> _ Do Not Fill In <br /> WATER WELL IRxI.LERS REPORT` §f ate Well No <br /> `Other Well No i' -- <br /> (Sertcona 76 d 0`7,�OZ6,dater Cade) RegiDn.�— <br /> (1) Driller: 'S � �I (2) Propased use or uses (check): (3) Equipment used <br /> Name ! ` _ =� -"' , 'z-;, Domestic tic Municipal .Q {cheek) <br /> Address � �?r -! '� 2{ Irrigation Industrial ❑ Rotary ❑ <br /> estic and Test well ❑ Cable <br /> License No. ��---Classificauon�_�+r3 �- 04) I rigation [] Dug well Q <br /> Owner- <br /> Name— of k check <br /> Name ' '�),. � � �% ��.r.- ) YPewor (check.) <br /> Addrexv� _ W c _. � _, � Eh � op New well ty Reconditioning of well 0 <br /> �^A Deepening existing well ❑ <br /> / -, � ��3Y�"7 f fo /V' p <br /> (5) Weil,10i C�" <br /> Total depth of well_ ft Give derids of formations penetrated,such as silt,peat,muck,sand,gravel, clay, shale, sand- <br /> stone,hardpan,rock Include size of gravel (diameter) -And sand (fine,medium,coarse),color <br /> Depth From Ground Surface of material,structure (loose,packed,cemented,soft,hard,brittle) <br /> It to_ _ ,ft �z <br /> 1 '-••---of '.'✓�) , -i'� a.'l r rtr,Ys 41— <br /> J-3_-.,ol <br /> ar ,r sr <br /> IN <br /> �.--�--•—"'.—fr >f-.�--�_" -� of <br /> IN IN <br /> aY J) w <br /> ~ s wa <br /> —_`—'--•_—+if ON <br /> If additional space is required,continue on DWR Form No 216—Supplement, and attach, to respective report copies <br /> (6) Casing left in well: <br /> LENG-rM DIAMETER SINGLE DOUBLE WEL09D ;rib P6R FOOT OR SMAfING BELOW <br /> Fr II4CH95 OTHER GAGE OF CASING GROUND SURFACE.FT <br /> Type and size of shoe or well ringj/VPVeided joints--IV Yes ❑ No <br /> D w R Foam No 246 REGIONAL WATER POLLU'rION CONTROL BOARD COPY , - <br />