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'1 ORIGINAL LOCATION <br /> NOT CMLCFCE <br /> F110 Qrlgtnal,OsRlicefe and lfipllctla rrlth tlts WATER WELL DRILLERS REPORT Do Not OW lis <br /> X-4GIONAL VATER POL xrrION n,(s.orlotart,carr,Tort,mater Code) 35707 <br /> �� <br /> � t7 5 $ 0A�j <br /> v <br /> CONTROL Bpm gyp__ STATE OF CALIFORNIA 0-1' Stwx VICH No..._.._._ <br /> - rr�rr�t•PProfr�4�.�irr) Q � Oefur Wa71 No... �� �� <br /> U) OWNER: <br /> N^me <br /> (11) WELL LOG: <br /> Total depth itDap4 of tam fated w41 f <br /> Address , <br /> � — Formwoa Drre+f3e►p tolee,ebvrctar,rfu oj,reMrlal,ort rtractnr <br /> it to <br /> (2) LOCATION of WELL: t <br /> r r f <br /> C.anasr L Owner's aa°mber,if aey— <br /> R►F'D x Sttoer , i <br /> (3) TYPE OF WORK (check): <br /> New bel} V Dftpemas ❑ ROemdinon;aa ❑ Abadan p <br /> 1f ebffXJVW "1,dace&etfetrA61 end edatre in lie=11 <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic S Industrial 0 Municipal ❑ Rotary, ❑ <br /> Irrxganon ❑ Test Well ❑ Other ❑ Cable E]Du Wei( <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLEP( DOUBLE Goa* „ <br /> or Diameter fmn to <br /> F-,0m ft.to ft Diem of Hon it ft <br /> O <br /> c <br /> - y <br /> if <br /> Type and uxe of shoe or wall nap '• L.,, S�xa of�sira[: `G'1. <br /> OaeaLo fvtnt ,fJ <br /> (7) PERFORATIONS: <br /> Type of parfarrmw and <br /> Srze ofEIT <br /> �. m,Imath.h <br /> From fr m f - Pori per row xowa Per it „ <br /> (8) CONSTRUCTION: _-- FOR nEF,, '.ai rimy Y <br /> .M a aarfan ma,ratT anal proNdad? ❑ Yu ❑No To what depth h <br /> vat—7&para sealed awe polleaaa? ❑Yoe ❑ No H ran,nota depth of errata <br /> From ft.to h « <br /> Method of Sealut w«h starad <br /> (9) WAXER XF.YJ€'44 a i¢ WELL DRAMS STATEMENT <br /> Depth.t whldr voter wp$pt lop,d Fbu Well uta jidkd w x4r, y f srr{dwboR and Sho report ar Hae to the beet o j <br /> c7 MY l+aotvlyd old lldtf <br /> t 4. f- AiAME <br /> .add 1e.e}efev petforatly Y - � � ft -- Ya - rm.ar t: frr�d or <br /> (10) WELL ` �fL"fls+�'_�:CR�f°�E3^ -- Addrw <br /> 4' -JAY <br /> r..a p—p"n amwo ed 3 x4 u tee,by whft? <br /> Yidde S*L with ft,draw down after Les. wou IMufar <br /> T.mprnwro of wage ...a rhpeierl er.lraa oade? Q Y. Na Ltceeaee �� _ Datedd r- t9 <br />