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ei <br /> OUPLJCA'rff WATER WELL DRILLERS REPORT Do Not F:ll In <br /> file Original,Duplleate and Trlpiicaie wlih the (Soctlaas 7076,701x,7079,Warn '�Te Code) 1'd O 64378 <br /> MGI0NAL WATER POLLUMN "` f, <br /> STATE OF CAIwIFORNtA St�j r�e Well lVa�_��4 <br /> L1�N RQ>L IIUomb,,) <br /> !a r!a1ProPrlrlr iromhrrl <br /> ) 00 1) WELL LOG: <br /> !Address, <br /> tni r Total depth it Depth 0f completed well {t <br /> Foemattoat Dnnrbr by eoJor,rbrrrrJrr,rlar of inelrr(dl,awd rlrucforr <br /> fs w ft <br /> (2) LO TI OF WELL: <br /> Cauaty � wner'a aum6ar,if saT— <br /> A F D Serres <br /> f � - <br /> w ' <br /> (3) TYPE OF WORK (check). <br /> Nero tvel Deepenmg i] Feco�idststtrsing 0 Abandon ❑ AV <br /> If abandonment,dercrtbe m4rrlal and pmr-edurr rn Ilnn 11 <br /> (4) PROPOSED USE (check)• (5) EQUIPMENT: / ? <br /> DomesticIndustrial ❑ Municipal ❑ Rotary ❑ <br /> Irttgatton (] Test Well ElOther ❑ Cable <br /> Dug Well <br /> (6) CASING INSTALLED• t If gravel packed Of� <br /> Y <br /> SINGLrW DOUBLE[] Gage <br /> Diameter ft <br /> From ft.to ft. Dsato <br /> m Wall IT=of Hort it. tt � <br /> Type and sue of shoe or well rtnR 44,Xsat p(araYolt <br /> brrerahe to <br /> (7) PERFORATIONS. <br /> rate of perforator Orad <br /> Sale of ufarsttoos en Iteipth, an , <br /> moan f. m ft Past <br /> per row 3L4ws ger ft <br /> � , s <br /> {a) CONSTRUC'T'ION: <br /> Was a surface taolnrr sed provided?>(Yes Q lin To what depth {t <br /> Ware any strata ualrd sonit pollni loop O YU ❑NO If ya,nose depth of terata <br /> From it <br /> ED ft <br /> Method of Sealing <br /> t-� Completed rr <br /> W4i! I9 <br /> (9) WATER LEVELS: WELL nKML'ER'S STATEMEINT <br /> Depth at which water was first foundIt This well was drillyd under my lrtrudlction and ibis rttort is trur to the brit of <br /> any knowledge and belref. <br /> Staadsne!teal hefors pesforatiaR <br /> tats Jexl after perfaratta)t ft (ltuson firm or cos <br /> r� 1 persesoo, fT}pr3 or Pr,oleJ? <br /> Address <br /> CIO) WLLL TESTS: <br /> Vas a pump test made! ❑Yon 0 No If yes,by wham? <br /> ��— $LG34ED r'd,-4� <br /> Yuki Ral/min wlth- _--_~ 1t draw down after hesrr _ <br /> Well Del er <br /> Trmperatnre o(Vare _ <br /> r \Vat a ehemial analys-r soda? f3Yee Q ho <br /> License LYLo <br /> 'W"elterrre]OR aaadc of well? ❑Yp Elmo <br /> 97023 0 er nom Ruin A Sao sir DWR [Be t1mv s 9q? <br />