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STATE OF CALIFORNIA <br />' Fue Origu+ upllcate and lnpticak with the SHEET I <br /> .. DEPARTMENT OF PUBLIC WORKS <br /> RESOURCES <br /> DIVISION Or WATER <br /> P ° Box -1 <br /> SACRAhdEN7D S CALIFORNIA DIVISION OF WATER RESOURCES <br /> . wM <br /> Do Not ill In <br /> WATER WELL DRILLERS REPORT" State Well No -� <br /> (setsJons goys,7077,cors,Water Code) Other Well No <br /> (I) F]rxller: <br /> (2) Proposed.ase orEases (check}: (3) Equipment used <br /> 1 Name— -____-- —__---- -- Domestic ,� Municipal ❑ (check) <br /> - -- <br /> Address <br /> Irrigation <br /> Irrigation ❑ Industrial ❑ Rotary Cl <br /> --� -- - _ Domestic and Test well <br /> License No ❑ Cable Qf <br /> �— Cla ~ cation»_ _a -- Irrigation Irrx Dug w E]g ❑ well <br /> Owner .rte Other____ ------ <br /> ___------ (4) Type of work check) <br /> Address— —_ _ _ New well Reconditioning of well ❑ <br /> _ ---------- - - -- - ------------- Deepening existing well ❑ <br /> (5) Well log. <br /> Total depth of well ft Give details of formations penetrated, such as silt, peat, much, sand, gravel, clay, shale, sand- <br /> 9toane,hardpan,rock Include size of gravel (diameter) and sand (fine, medium,coarse), color <br /> Depth From Ground Surface of maternal,structure (loose,packed, cemented, soft,hard,brittle) <br /> ft <br /> - —� •— -- — <br /> xj� „ »----- <br /> � ar <br /> -- - —-- -- L v - a I r <br /> If additional space is required, continue on DWR Form No 246 Supplement, and attach to respective report copies <br /> (6) Casing left an well: <br /> LENGTH DIAMETER <br /> SIN LE DOUBLE WELDED Ld5 PER FOOT OR SEATING BELOW <br /> —- IN EOTHER <br /> S GAGE OF CASING GROUND SURFACE FT <br /> - - -- - ------------ <br /> - - --- --- - - - -- Y -- <br /> ------ ----- --- ------ -- <br /> — - r <br /> ---------- <br /> Type and size of shoe or well rill/ <br /> in _� Yelded joint es ❑ No <br /> D W R FORM No 246 REGIONAL WATER POLLUTION CONTROL BOARD COPY <br /> 232715 50 SON aL11N SPO <br />