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Leri 110) 0l <br /> ORIGINAL i_ <br /> + DoVot <br /> 1 File Original,Duplicate and Triplicate with the WATER WELL DRILLERS REPORT <br /> DIVISION OF W&TER RESOUR(ES (sections 7074,7077,7471,ovater Code] <br /> I _ State Nell Na <br /> P o OX1074 STATE OF CALIPORN IA�-OEPARTMETIT OF PUBLIC WORKS �CJ�` <br /> SACRAMENTO p CALIFORNIA DIVISION of WATER RESOURCES Other Well N0.:L-r...r / w <br /> ' 1477 muAltz, M. ToNEs 3/yy us H/ J3 Region— <br /> i) DRILLER. person, r rporatton) (8) LOC ION OF LL• a <br /> Name a �/ County J <br /> Address R F P or since No <br /> OWNER: • + r `� r1 r r J' <br /> Namef ilr�ir L ej G <br /> Address (9) WELL LOG. <br /> Toni depth of wen <br /> For nauan: Mention size of water gravel— <br /> (2) Proposed Use (Check) Equipment it to it e <br /> Domestic Industrial ❑ Rotary <br /> Cable9 r- <br /> Irngatfon ❑ Test Well ❑ Dug Well [f? c..()-A <br /> Municipal ❑ Other ❑ Other ❑ <br /> (3) CASING: f - <br /> it of to —hr,/go tanns left m erell <br /> Type and size of shoe or well ring <br /> ` (4) PERFORATIONS: <br /> ype of perforator used <br /> Perforated it to it boles per in <br /> uU <br /> 1� <br /> . V <br /> Diameter of perforations in length sn <br /> (5) WATER LEVELS <br /> Was eketne log atade of well? El Yet [] No If yn Itaeh Copy <br /> i <br /> Depth at which water was first found ft <br /> Standing level before perforating it <br /> Standing level after perforating fc <br /> Note your obseragt,on of any change in water level whsle drilling <br /> Wo,a surface sanitary zeal provided? <br /> (6) WELL PUMPING TEST: Work;carted 1 �� Completed Iyf <br /> Capacity gal/men it dray down Dat.of Report ( <br /> —e <br /> �ry t9 <br /> WELL DRILLERS STATEMENT <br /> Wan well gnvel packed? Thu well woe drilled under cry jurisdiction and this report a true to the h. <br /> Were any Strata waled against pollution? o/my knowledge and 6elrCf �/ r <br /> Attach <br /> .rmperature Was a chemical analysis model copy [STGNED]___.....-- I_ <br /> If abandoned was well capped? .- r �— ..� Will Drsllrr <br /> (7) TYPE OF WORK (check) License No— _ _-- Classification <br /> New well)4 Reconditioning of well ❑ Dated <br /> Deepening existing well M ■4370 7$1 sort OUIN 0 sro <br />