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y ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill In <br /> File Original,Duplicate and Triplicate with the (sactrnna 7076,7077 7078,'Water code) N? 31910 <br /> REGIONAL WATER POLLUTION L St:te Well No <br /> CONTROL BOARD No-1-3— STATE OF CALIFORNIA 9 w,^-r <br /> (local appropriate wmnber) Other Well No <br /> 0O ER f (11) WELL LOG- <br /> me f Toul depth ft Depth of completed well Z/ ft <br /> Address r F4rrna[rOn Detntbr by rotor,cberar1rr na f waterlal,acrd itracirn <br /> e <br /> � it to ft <br /> (2) OC ION OF WELL- t <br /> �.r w <br /> caner a number tf any-- ` <br /> R F or S t No , ! wc <br /> i <br /> 1 1 � •♦ rt <br /> l / <br /> tip- <br /> (3) <br /> (3) TYPE CSF WORK (check): <br /> New well 1pDeepening ❑ Reeondtnoning ❑ Abandon ❑ <br /> if abandonment,describe material and procedure in Item 11 <br /> (4) PROPOSED USE (check). (5) EQUIPMENT- <br /> Domestic ti Industrial ❑ Municipal ❑ Rotary ( � <br /> Irngation E3Test Well El Ocher 13 Dug <br /> ❑ <br /> Dug Well ❑ <br /> (6) CASING INS'T'ALLED If gravel packed <br /> i <br /> SINGLE ©-DOUBLE Gage ` <br /> .r or Diameter from to — <br /> From 4t t ftum Wall of Bore le"Y ft It <br /> Type and size of shoe or well ring Site of gravel <br /> Deacrabe?oast , <br /> (7) PERFORAT NS. <br /> Type of perforator used <br /> Size of perforations in,length b 1� in <br /> From ` fc w ft Perf per rov Roxi per it <br /> (B) CONSTRUCTION <br /> Was a surface sanitary seal provided? 4P-T" ❑ No To what depth ft <br /> Were any strata sealed agaantt pollution? 13-I'ea ❑ No If yet note depth of strata <br /> From <br /> it to it <br /> Method of Seating 7� Work rtartea E9 r�~eompliii l( <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> _ Tblt well was drilled tinder my 1urtrdaehon and tbfs rrport rs trur to the best of <br /> Depth at which wirer was fint found it my knowledge and brlwf <br /> I <br /> idang level before perforating [ f t NAME 117414/ �l I � <br /> daitg level after perforating ie ft ( non nr—tptratiwi) r7 yPed or priwtrdJ <br /> Address <br /> 1 o) WELL mTESTS: <br /> r: I <br /> Was a pup test made? 0 Yet rJ i•u If yes by whom? ��'� <br /> [SICKED) <br /> Yield <br /> / Well DrfJ _ <br /> Temperature of water Was a chemical analyaaa trade? Yes a-"* License N0.) <br /> r <br /> Was electric log made of well? 0Yrs t!T'7qa� <br /> asaaa a as SOM cUttt QQ aro n•u� ^--Ca ^'^ ^"` _ sat <br />