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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File Original,Duplicate and Triplicafe with the ` 0S (SeetiOns 7076,7077,7078,Water Cede) N U 56567 <br /> REGIO11AL WATER POLLUTION _ ��T �+ <br /> C) STATE OF CALIFORNIA State Well No------ L±y./1+2'!�,.__. <br /> CONTROL BOARD No.— n /� <br /> q & <br /> r� <br /> '�S r ' Other Well No. <br /> r•lfproprl•re nrembrr) r �( iJn!.4IQ.�+..0-�.( -. <br /> x <br /> OWNER: (11) WELL LOG: <br /> Namc 17 � _ <br /> Total depth 214e fr. Depth of completed a,rll �0'C ft. <br /> Address ( Fnrmalion: D'ru'b'by'.10"r6e+•rlrt,size of m.1-1.red srrvrsvre. <br /> ft.to ti it. .( <br /> a <br /> (2) LOCATION OF LLL: •31 <br /> Covntr ! z Owner's number,if any-- <br /> R.F.1).-oStreet No. tc •. <br /> ZY <br /> 7z <br /> � <br /> (3) TYPE OF WORK (check): <br /> New well X Deepening ❑ Reconditioning ❑ Abandon ❑ <br /> If abandonment,deirribe material and procedure in firm I1, <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: " <br /> Domestic ® Industrial ❑ Municipal C Rotary 9 <br /> Irrigation ❑ Test Well ❑ Other n Cable F-1 _ <br /> Dug Well <br /> (6) CASING INSTALLED: If gravel paclted „ <br /> SINGLE ® DOUBLE <br /> or Diamener from ro <br /> Prom ft, ro l ft. Diem. ! Rall of flare fr. ft. <br /> Type and-e of shot or well ring Size of gravel: , <br /> Describe joint <br /> (7) PERFORATIONS: <br /> Type of perforator need <br /> Size of perforations in.,IeaRth,by <br /> From ft,to ft. Ptrf,per roar Re-per ft. „ <br /> (S) CONSTRUCTION: <br /> Was.s surface sanitary teat provided) ❑ Yea F-1 No To that depthUSE R <br /> r <br /> Were say strata sealed against pollution? Yes ❑ No If yes,note depth of strata <br /> From -r ft,to /C <br /> Method of Sealing e gp / <br /> .-- _ work started <br /> (9) WATER LEVELS; WELL DRILLER'S STATEMENT: <br /> ? <br /> Depth at which water was firer found This well was drilled under my jurisdiction and this rrporl is trete to the best of <br /> fr, ink,knowledge and belief. <br /> standing level before perfvrstinR it NAME <br /> 1 R seed after perforatinx fee 1 t _ F i <br /> _ -- -- - - - - 1tYi rgl Cr lbs• tion! F� •. o •-� l vprd vrf.pri+yrdl l.. <br /> Address <br /> (10) WELL TESTS: <br /> a7u a paernp ua[mallei ❑ Yes ❑ No 1(yes,by wham? �_ <br /> Yield: Rat./tnio. with ft.draw down after }tn, (SIGNED)................ _____________l.l_.__.__....._._-•_-_-••-._._.__..._.:_._-..._ <br /> Will Drills t'------•----•-•--.... <br /> Temperature of water Was a chemical analysis made? ❑ Yes ❑ No License No................ <br /> -_--. .... Dated....---...._.. <br /> we,eltetric loJt made of well? ❑ Yes ❑No nn s 19 <br /> 67023.6-37 Es.] <br /> OM QUIN apo DWR 188 (REV. 9.54) <br />