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ORIGINAL PATER WELL DRILLERS REPORT Do Not Fill P <br /> File original.Duplicate and Trlplieate with the (sections sore,7077 7071,n ater cad.) ��...��ANT® b'71 td 2 <br /> REGIONAL WA'T'ER POLLUTION (a ~ 14 ID <br /> CONTROL BOARD No STATE OF CALIFORNIA�� <br /> ••art appropriate sorbrr) Other WdI No.-- <br /> I <br /> t) OIMIMR. (I I) WELL LOC: <br /> Name Total depth it Depth of completed well It <br /> Addres Formaxion Describe by color,ebarrcter,iszr at erstrrrol on rlrarlare <br /> ft to it <br /> {{2�ATI OF WELL: <br /> r.OWa[r ' weer r AmalbV if amr--- <br /> R F Dar§Fr e Jy <br /> AIV ZIr <br /> J <br /> (3) TYPE OF W (che,fa): <br /> New WellDeepening ❑ RerandrtionwS ❑ Abandon ❑ zw <br /> If obandontKent,describe maters1 and proredure m Item II <br /> (4) PROPOSED USE (check) (S) EQUIPMENT: <br /> Domestic ❑ Industrial ❑ Muruc;pal ❑ Rotary <br /> Irrigation Test Well ❑ Other ❑ Cable <br /> Dug Well JS 154 <br /> (G) CASING INSTALLED. If gravel packed <br /> SINGLE 04LI8LC,::j Gage <br /> or Dramarer Isom [a <br /> From ft co ft Dtam Wall of Sore it ft <br /> A <br /> Trp.and a,r.of[hoe ar well Size of anv.1 <br /> Demrihe Imat za&7 OV <br /> (7) PERFORATIONS., <br /> Tvpe of perforate-and <br /> Size of per£or.[ioer in. length,by an <br /> From ft to ft Perf per raw Raw,par it <br /> (8) CONSTRUCTION: <br /> War a sarfaca,amara seal Provided? xye3 ❑ No To whae depth 11 ft <br /> Were any strata sealed ascan pollutiopa Q Yes ❑ No if ler non depth of mart <br /> From ft to tc <br /> ti <br /> Method of Sealing work rtar<ad 19 _ Completed <br /> (9) WATER LEVELS: WELL DRILI-ER's STATEMENT <br /> This uVa was drilled ander my?urudictian and this report ss true to the best of <br /> Depth at which water wag;&rgt[amid tt my knowledge belief s 1 <br /> sta-hum level before parfaraaab it NAME � 1 f r ) ' <br /> iSnR lava afar prrf_reetns _ _ --- _'J ft erseto ft`mor carp rat J Ar aJ) 1 <br /> —" Add . /!I' <br /> (I a) WELL TESTS: <br /> Was a paamp pat made? 0 Ver ❑ No If 70,b7 whom? <br /> Yield Kul/tun with it draw down atter bra. [ AP40— -SIGN"] <br /> 1p'rA DrlAler <br /> Temperature of water was a chemical analrou model 0 Yes 0 No Laeense Na, -- — Dated.........__ <br />