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LOCATION NOT CHECKr7 <br /> IORIGINAL WATER WELL DRILLERS REPORT Do Not Fill in <br /> File Original,Duplicate and Triplicate with the (sect,ens 7071,7077,7071,Water Cade! -9 � r_ N� 39893 <br /> REGIONAL WATER POLLUTION �Ll ell",1 • <br /> CONTROL BOARD No STATE OF CALIFORNIA State Well No <br /> (!cone a/`roprlete wwLn) g1) �. <br /> ,.•r,,,�,.-,�_ / Ocher Well No._ <br /> 1) OWNER: <br /> (I_ I) WELL LOG <br /> Name • <br /> Teal depth 220 ft Depth of completed well ft <br /> Address <br /> i�OT'?'�it Ori Cel' ?1 f e Fermauon Arrrrebe by rolor etw..rtrr ar:r <br /> ? Cff eaelnfrf 11111 rrrrrrrre i <br /> 0 it to 2 ft 0011 <br />' (2) LOCATION OF WELL. 141 oft blue yc ay <br /> County yl ^ty owaer r number if any-- L mud <br /> R P D or Street Ne2 and TTQO <br /> 8 Blue clay <br /> 98 08 Blue clay C: sna re <br /> T4N -.R5E 138 Blue cls <br /> 8 Sand <br /> 17 <br /> (s) TYPE OF WORK141, ) Blue claysea e <br /> (check): Sand <br /> New well P9 Deepening ❑ Recondtnontng 0 Abandon ❑ 173 7 0 ,Soft sandy blue cls <br /> I f abandonment,describe material and procedure in Item I11 7B17-le <br /> clay s.-la e <br /> (4) PROPOSED USE (check) (5) EQUIPMENT: <br /> Domestic ❑ Industrial ❑ Mmuclpal ❑ Rotary 99 <br /> Irngatlon ❑ TestWell ® Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE❑ DOUBLE Gage <br /> or Diameter from to <br /> From it to ft Dsam Wall of Sere it ft <br /> ^`•.. <br /> Type sad stu of shoe or well riot Size of Srarel <br /> n <br /> De+cnbe sotnc �G 1 r�r ,�`_ <br /> (7) PERFORATIONS: <br /> Type or perforator used '1• <br /> n r., <br /> Silt of perforations sn,Imltth by M. <br /> Fraffn ft to ft Parr per row Rows per It. , <br /> I <br /> (8) CONSTRUCTION: <br /> Was a surface unitary epi praysdad? ❑ 7q [a No To what depth it <br /> Wen any strata reeled atssdt pollotmml ❑ Yes ❑ No If yes note depth of strata <br /> From ft t, rt A <br /> Method Of Sealing Work started C Completed 19 <br /> i � r <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> Depth et which water was(est rft This well was drilled under my jurisdiction and Ibis report is true to the best of <br /> eaad <br /> brfoy knowledge and belief <br /> ms Isvel re perrorse,xii naft <br /> NAME <br /> A level after ptrforaun, ft (Prrwn qrm or corpc.rauunl i Type1 w pn,sulJ <br /> (I a) WELL TESTS: Address ,2 lh rt lir '-;"',r <br /> Was a ptuop teat made? 0 Yp ❑ No If Yes,by wh*m? <br /> Yield= nal/mss withft dew down ajar hes (SIGNED! .. _ .. ..____..�........� _».. <br /> �-- <br /> Tetnpersture of water Was a ahomsnl saslystt made? [] Yee ❑ Ne `` Well Dr/Her <br /> License NaDared_ 9/10/57 ,,,-w_ <br /> v44*Itatrtc Ink made*f well? ❑ Y*a ❑1% *15111111 3 34 ser ouirs Q aro DWR FORM No tie 4I11EV 2till <br />