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ORIGINAL, STATE OF CALIFORNIA SKEET <br /> 39-928 <br /> File Original DaPllcale and Triplicate with the DEPARTMENT OF PUBLIC WORKS <br /> alYulax Of WATER RESOIlR(lS DIVISION 0 WATER RESOURCES <br /> P O BOX T079 <br /> SACRAMENTO 5 CALIFORNIA <br /> . Do Not Fill In <br /> WATER WELL DR�LERS REPORT _ State Well No <br /> ,1 Other Well No _ r -�_!-__- <br /> (Sections 7076,70;"7,7ti07>Q ter Cade) <br /> , 1 � <br /> (I) Driller �� -� (2) Proposed use or uses (check) (3) Equipment used <br /> Name___ _ i __A r_ �' :. Domestic ❑ IMunlcipal ❑ (check) <br /> Address____ __�__'_�L _�-' �¢ -'r ' Irrigation (� Industnal [IRotary ❑ <br /> omestic and Test well ❑ Cable <br /> ❑ Dug well ❑ <br /> License No-_ __— <br /> r atkon w^ <br /> ether_ Other ____ ___ <br /> Owner <br /> Name___ _ (4) a of work check <br /> Address _ �_ ` __' _ �__ _ d _ 3�y ...m New well Reconditioning of well ❑ <br /> - - ------- - - Deep Ing exlstm well ❑ <br /> 5) Vel log r� <br /> Total depth of well p(_ _ft Give details of formations penetrated, such as silt, peat, mucic, 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 /> to--- _ ft <br /> as <br /> t <br /> �-s IL <br /> _ =a <br /> r ,. . <br /> o <br /> .I )) fr <br /> r, if <br /> __-_ ,/ ff <br /> r 1) <br /> FORas )a u <br /> _- --- -- ------ - — ) 1 v7— ■ <br /> If additional space is required, continue on DWR Form No 246--Supplement, and attach to respective report copies <br /> (6) Casing left in well <br /> LENGTH DIAMETER SINGLE DOUBLE WELDED LBB PER FOOT OR SEATING BELOW <br /> FT INCHES OTHER GAGE OF CASING GROUND SURFACE FT <br /> Type and size of shoe or well nn �P Welded joints---M Yes ❑ No <br /> D w R FORM NO 246 REGIONAL WATER POLLUTION CONTROL BOARD COPY 23471 3 go 40M QWLN sro <br />