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-ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill in <br /> File Original,Dupilcate and Triplicate with the (s*ations 7076,7077,7071,Water Cede) <br /> REGIONAL VpATER. POLLUTION N9 <br /> 1131 <br /> STATE OF CALIFORNIA 5tafv'WellNo. M <br /> cOzvrxoL BOARD xn� A/�J ��, 6� <br /> �4WH dPPropri.te nrabrrJ �..� /t �SI Other Well No,u-l�!�.... __Q.- - --------_'- <br /> a - - <br /> x) OWNER, (12) WELL LOG: <br /> Name Total depth <br /> .S 6J St. Depth of eempletcd wdI fr <br /> Addressr Furroation: Urs- ibr by rotor,cb.r te,,size of nasrrrref,rrti rl rerlerr, <br /> ft.to ft. <br /> (z) L CATION OF WEL : <br /> County Owner's number,if env— ' <br /> R.F.D.or Stre o, - <br /> 2 _ r• <br /> 3 TYPE .. <br /> ( ) O)" WORS (check): <br /> New well19 Y" JS <br /> Deepening ❑ Reconditioning ❑ Abandon Cl — <br /> x <br /> If abandonment,describe material and Procedure in Item I]. �• <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: ijg7 <br /> Domestic Industrial ❑ Municipal ❑ Rotary i t <br /> Irrigation ❑ Test Well ❑ Other Cable ,El - <br /> Dt3g Well Ej , <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLIn JK DOUBLE 7 tae <br /> or Diameter from to <br /> From fr.ro it, Dia-, Wall of Bore it. ft. _ <br /> Type and size of-hoe or well ring Size of gravel-- .. , <br /> Describe joint .. <br /> (7) PERFORATIONS: <br /> Type of perforator used may, <br /> Size of perfor.tions in..lentth,by in. " <br /> Froart fr.w ft. Perf.per row Rcwa per it. <br /> (B) CONSTRUCTION: t ' JAL <br /> l <br /> Was x turfaes sanitary teal provided? ❑ Yea E] No To whet depth ft. •• <br /> Were any strata sealed agsinae pollution? Yet El No If yea,note depth of strata <br /> From ft.to <br /> Method of Sealing _ Work rtxrted <br /> (9) WATER LEVELS: WELL DRILL 'S STATEMENT: <br /> Depth at which water was Set found ft. Tbis well was drilled tinder my jurisdiction snd ibis "Port it true to the best of <br /> rely kyrawkdg grid belkf. <br /> . St-ading level before perforating <br /> NAM <br /> :at Irv*,after perforating <br /> ft, (e stet,$r ,or CrepC Ln Ty u prier d) <br /> NNW <br /> (I 0) WELL TESTS: Addrets <br /> drat a pumP test made? 0 Yet ❑ No If Tet.by whom? <br /> Yuldl gsl./min,with ft.draw down after <br /> _..-- <br /> Tooperature of wer Was a chemical snalyaia made? ❑ Yea C3No 1•rll Arfltrr <br /> License Na., - ._-------s 19._.......-_. <br /> Val electric log made of well? [3 Y. �No - - <br /> 57025 6-57 sole QUIN �N spo DWR 1e8 (REV.9.54) <br />