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1u.IL l <br /> Do <br />" ORIGINAL WATER WELL DRILLERS REPORT <br /> Not Fill In <br /> File Oflgmal,Duplicate and Triplicate with the (Seetroar`076 7077 7076 Nearer codrl N« 55280 <br /> REGIONAL WATER POLLUTION State Well No ` <br /> ONTROL ROARD No STATE OF CALIFORNIA <br /> ��rt approprsalr nambrr) • Offer Well No M f <br /> (1) OWNER (11) WELL <br /> j LOG / <br /> Name �� � '2 � Total drpth 1'0 0 f Depth of compirrcd veil <br /> Address f Frrrmaxron Dnmhr h)rotor rbarar fn rite of naNrrrsl no rarlvre <br /> it to it <br /> (2) LOCATION OF WEL . /41 <br /> J� <br /> Cauntt r Owner a number tf Ano-- � T� <br /> R F D or Stre7274 n +frLjz <br /> Z <br /> 21 <br /> y <br /> (3) TYPE OF WORK (check) 112" <br /> NEW well � Deepening ❑ Reconditioning ❑ Abandon ❑ -4 -� <br /> if abandonment descrrbe aaaatertal and procedure in Item 11 <br /> (4) PROPOSED USE (check) (5) EQUIPMENT /'r <br /> Domestic Industrial ❑ Municipal ❑ Rotary <br /> Cable <br /> Irrigationu Test`H'z:l ❑ 0--herDug Well ❑ <br /> (6) CASING INSTALLED It gravel packed <br /> SINGLE X DOUBLE Gan <br /> o D arscrrr f Orn +a <br /> From <br /> it to it Dram �Y all of Barr rt ft <br /> • Ahr .� z <br /> i <br /> 13 P.snit uee of shoe or well rang '( x Srze of grxret <br /> Deacnbe inane <br /> (7) PERFORATIONS: <br /> Type of perforator used <br /> .size of perforataom sn length by ra <br /> From ft to ft Perf per rota Rcwa per it C <br /> r <br /> - 06 <br /> (8) CONSTRUCTION <br /> Was a surface sanitary seal provtdcd} ❑ Yea Lj No To what depth ft <br /> Were say strata sealed against pollution} Yes ❑ No If yes note depth of strata <br /> From rt to ft <br /> Method of Sealing ` �1-y_ Work sorted =9 comp)—ti 3a <br /> (9) WATER LEVELS. WELL DRILLER'S STATEMENT <br /> This uell tuns drilled rrrrdrr airy lrirrsdicfiorr and fbii rrhori is true to the best of <br /> Depth at which water was fent found ;S-10 it nil'knou ledge and belief <br /> AMtng level before perforating .�ea- it NAME <br /> ding level after perforating it lPi-son Arm cr—rr+en1111 i1'r brit rn s eemed) <br /> Address <br /> (10) WELL TESTS. <br /> WAS a pump test made} © Yea ❑ No If yes by-barna �l <br /> YseSIGN EI71 <br /> ld gal/M. -,th ft draw down after his Wr!! rifer <br /> Temperature of w.ur Was.chemraal analyse made} ❑ Yes ❑ No License No-- _ Dated _ > 19 <br /> Vas.leers M Ys n w.. <br />