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rJ(+ORRGINALWATER WELL DRILLERS REPORT Do Not Fill in <br /> File Original,Duplicate and Triplicate with the (s.ctroos 7016 7011 1012,Warr Code) w t,d N l) 55269_5 96 9 C Q <br /> REGIONAL WA'T'ER POLLUTION 4;, Welf Na L _ _ <br /> CONTROL BOARD No STATE OF CALIFORNIA -- - <br /> ere appropriate number) r-1 '� Ocher Well No <br /> t) OWNER (11) WELL LOG <br /> Name ..yy <br /> Toch depth L—�4 4 Depth of�omp{rmd <br /> Address Formanon Descry&by a olor character rsze of­ter,al and ttruclute <br /> ft to ft <br /> e— <br /> (2) LOCATIO OF WEet <br /> Count} 0-nor s umber if any— 161C.r <br /> R Ir D or S et Na <br /> (3) TYPE OF WORK (checA) <br /> f <br /> New well J9 Deepening ❑ Reconditioning ❑ Abandon ❑ <br /> If abandonment,describe material and procedure in Items 11 <br /> 1 40- <br /> (4) PROPOSED USE (check) (5) EQUIPMENT f <br /> Domestic ❑ Industrial ❑ Municipal ❑ Rotary ❑ J « <br /> IrrYgation ❑ Test Well ❑ Other ❑ Cable ,g __ _ zL <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE �_gj DOUBLE �:: Gage <br /> Diameter from to <br /> From it to it Dsam Tai! of Bore ft ft <br /> 1 ype and srse of shot or well ring ^ i Size of gravel <br /> D..'zcbe joint <br /> (7) PERFORATIONS: <br /> Type of perforator used e <br /> Slue of perforauons a length by as <br /> From It m ft Pert per row Row.per it <br /> (8) CONSTRUCTION <br /> woo a surfaec san,rsry seal provided? 0 Yea 0 No To what deprh ft <br /> Were Bay sitar.scaled agwit.t pollut oo) AYes 0 No If ya note depth of sent. <br /> From. fr to it __ <br /> Method of Seallmg 7-9- worst atarml ,9 <br /> y' 4um Pieced �� �� 79�J <br /> (9) WATER LEVELS: WELL DRILLERS STATEMENT <br /> This well wai drilled ltnder my Jurisdiction and this report is true to the best of <br /> Depth at which water was firtt found ft my knowledge and belief <br /> iftg levek 6efare perforating it NAME } y ,. , � a ), I y <br /> ex level after perforating ft WP o him ur wrpcnr„n� r iT yped r,r pr lcdl <br /> Address <br /> (10) WELL TESTS <br /> W..a pump test modes ❑ Yrs 0 No If yes 6y whom? <br /> '(,rid gal /men with ft draw down after bra <br /> {tar((Dr,?ter <br /> Temperature of warm Woo a chomr 1 analysis made? ❑ Yes <br /> Cl No License No _ Dated <br /> w v errcerrc ioR made of well? [] Yes [] No <br />