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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br />' <br /> File Original,Duplicate and Triplicate with the (5ectmni 7076,7077 707E water cede) /.l M�U 5.5270 <br /> REGIONAL WATER POLLUTION ` a <br /> CONTROL BOA STATE OF CALIFORNIA State Well No r w <br /> Re, No� <br /> r!apprapnafr akrytber) 7 Other WellNo <br /> I) OWNER' 01) WELL LOG <br /> amt ' Total depth Z !� v <br /> it Depth of completed well {t <br /> Address f , Formartoo ",_be by color rbararfrr,nze al mafrnaf •ad asrarlure <br /> ft to ft <br /> (2) L CATION OF L D <br /> Count Owner s number if any— <br /> R F D or StR'No <br /> 40 <br />' (3) TYPE OF WORK (check) Zp <br /> New well ❑ Deepening X Reconditioning ❑ Abandon ❑ <br /> If abandonment,describe anaterral and procedure to Item 11 <br /> (4) PROPOSED USE (check) (5) EQUIPMENT- <br /> Domestic ❑ Industrial [❑ Municipal [] Rotary ❑ <br /> IrngatlonTest Well ❑ Other ❑ Cable <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE C& DOUBLE 7 e <br /> Ga <br /> S Demeter from ro - <br /> From it to or of Bore ft <br /> (t Dtam VaIE ft <br /> t.' <br /> Type and size of shoe or well rang lye Site of gravel <br /> Dercrtbe pint <br /> (7) PERFORATIONS: .4 ea"� <br /> Typere .., �.. .r <br /> of perforator o , a!` - <br /> Size of perforations to,length by to <br /> From rt m ft Perf per rov Ran.per ft <br /> i <br /> (8) CONSTRUCTION: t Y <br /> Was a surface unitary seal provided? ❑ Yea Cl No To what depth it Y `1' <br /> Vote any strata scaled against pollutsonl Yea ❑ No If ya no a depth of strata <br /> From <br /> ft <br /> .�eo It <br /> Method of Seating <br /> _ __ Work carted � ' i96� Completed , ..5— 19(tp <br /> (9) WATER LEVELS: / T WELL DRILLER'S STATEMENT <br /> Depth at which water was first found <br /> LP Q it This wetl was drilled under my lurrsdfctron attd this report rs {este to the,best of <br /> my knowledge and belief <br /> - 1d.ag level before perforating ft ( ...- <br /> 1 NAME /� 1 <br /> trir,[.c�.� CL1 �+ y`g level alter perforating s <br /> ✓ it (Person firm or curpera pan y Typed or prixfrdy <br /> WELL TESTS: Address t <br /> Was a pump tee made? C3 Yes {] No If yes,b7 whom? <br /> Yield Sal/=a with it draw down after het [SIGNED) _ <br /> i <br /> Writ Driller <br /> Temperature of water Was a chemical analysis made? 13Yes C:) No <br /> License No _ Dated _ 19 <br /> Was electric log made of well? ❑ Yes ❑ No <br /> 57025 a 57 50M QUER L spo DWR IS 8,(REV 3 541 <br />