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NOV 7 1967 <br /> ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> His Original,D11pllcale and Triplicate with the (srct.oar 70749,as»,7071.Water Cade) NY 55280 <br /> REGIONAL WATER POLLUTION State Well -- <br /> CONTROL BOARD No STATE OF CALIFORNIA Other'Well No _ — <br />• ert."'oPrf.?e ri...'brr) <br /> (1) OWNER (1 1) WELL LOG- <br /> /-_7 Total depth <br /> ��` is Depth of complerrd re]] 1d fr <br /> Address J Q Formation Drrr+rbr oy role, rb.rer}n rite of molerul .ttd r reeture <br /> ft to ft <br /> (2) LOCATION OF WELL <br /> county orner..member .f a.-- <br /> 77-3 <br /> R F D or Srre Vag <br /> Z <br /> y r <br /> (3) TYPE OF WORK (check): f Z <br /> New well 3? Deepening ❑ Recondtuoning ❑ Abandon © f Q <br /> If aband"menj describe rnafrrral and procedure in Rem 11 0 <br /> (4) PROPOSED USE (check)- (5) EQUIPMENT• <br /> Domestic }R Industrial ❑ Muruclpa! ❑ Rotary ❑ <br /> Irngation E] Test Well [] Other El Dug <br /> Duugg <br /> Wel! ❑ <br /> (6) CASING INSTALLED. If gravel packed <br /> SINGLES DOUBLE ::: Gate <br /> o D.meter f am to <br /> From it to it At.m 'mill of Barr it it <br />. D / a 'e, /.?- <br /> T, <br /> zTt pe..d 1st of'hot or.ell not X x aur of 6 Art <br /> Dose.be cant <br /> (7) PERFORATIONS <br /> r.pr of prrforator used - - -- <br /> StXe of prforatioa' n lenesh by 1O <br /> From ft rn it perf per rov Ro.,per ft <br /> �r>s <br /> (8) CONSTRUCTION <br /> W., . turf.ce.aa.tary i.d provided? ❑ Yea ❑ No To rhes depth it <br /> mere Day straw ceded quart pollution} 91L Yon ❑ No If yn Dote depth of strata <br /> From fr to it <br /> Method of Sealing work trtrted a9 / coa.plrttd t. <br /> (9) WATER LEVELS: WELL DRILLER S ST 4TEMENT <br /> Thu well teat drilled Under my lurrrdrefron and thrr rrporf n Irue to the br <br /> Depth at rhich rater r,first found it my k«owledge and belief <br /> -idtDa lira1 bolos pofu uj; ,Z7 it ;`TAME u <br /> d'oa ler.]after perforation f ft tP r. arm tar,.,t rt.r�t,.., rT}ped nr rnaud) <br /> Address <br /> (10) WELL TESTS <br /> We.a pump t..t D..de? ❑ Yee ❑ No If Tn by-hem? - <br /> Y..ad Kai/me r'tb it draw dors after bn well flier <br /> Tornpereture of,Deer nue.a ch.D'.nl.a.lym made? [l Yee ❑ No Lteense No -- Dated- <br /> Wa.46.tr.t log made of..Il? ❑ Yn ❑ 130 ._„_.----- <br />