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ORIGINAL WATER WELL DRILLERS REPORT Do Not Fill he <br /> File Original,Duplicate and Triplicate with the (settaona 7076,7017,7076,water cede) �� 64397 - <br /> REGIONAL WATER POLLUTION <br /> STATE OF CAL{FORNIA/ l 4 State V�ellNo <br /> CONTROL BOARD No _ __ <br /> — f —� - rte' <br /> r�rtrt r ro rt / Othet Well Np�,� � <br /> DP D rtr camber} f-- <br /> 1 OWNS (I I) WELL LOG. a <br /> Name 0Total eh de <br /> p 6 it Depth of torupieeed rel) it <br /> Address } Formation Drsr•rtrr by rotor rba•artrr,Istr of+netnirf and ararttrrr <br /> it to <br /> fc J <br /> (2) L ATION OF WELL: <br /> Covnc ner s number of any— <br /> R F D or Street <br /> 1001 <br /> (3) TYPE OF WORK (check). <br /> New well ❑ Deepening ]� Recondtnoning ❑ Abandon 0 <br /> If abandonment,describe materiaal ander procedure in Bene I I <br /> (4) PROPOSED USE (check) (5) EQUIPMENT <br /> DOmeStiC [❑ Industrial ❑ Municipal ❑ Rotary <br /> Irrigation 4 Test Well ❑ Other C] Cable <br /> Dug Well <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLEA DOUBLE Gap <br /> or Diameter from to <br /> From f to it Dram email of Bort it ft <br /> y <br /> T,,pe and nze of shoe or,retI ring Size of gravel <br /> Describe joint <br /> (7) PERFORATIONS <br /> Type of perforator used <br /> Size of perfarationi / in length by en <br /> Fromlf�` ii ttrr 'i!" 410 )1 <br /> fr to ft Per( per row Rows par it <br /> (8) CONSTRUCTION '•-. <br /> lC'rs a turfaca st nitar7 sea!provided? ❑ Yes [3 No To what depth ft t + <br /> V7erc any lista riled gunst polivrion? ❑ Yes Li No if Yes note depth of,crata '•�"'- ! "`d"s <br /> From )t re it <br /> Nlethiod of Sealzng <br /> Completed <br /> (9) WATER LEVELS- WELL DRILLER'S STATEMENT <br /> round it <br /> Tbts wrll wes dfdled Under my)urisdretaon aria tots report rr true to the brit of <br /> Drpch a= whish wrier was first ft my knowledge and beeuf <br /> nding level betore perforating <br /> ft ::'� = vr`i i ?BILLING & F. <br /> NAME VALLL'Y <br /> ane Ierei after p.etuaetraR <br /> ft tri m ur sae pLraupn7 <br /> i Tyre ar D•a•rrsy <br /> Address 06f` <br /> (I 0) WELL TESTS: <br /> V7as a pump etsr made) Q Yes © No If yea b7 whams <br /> Yield qal/ensu with fr draw down after hie <br /> Temperature of'anter Was a themae <br /> e—) alysis made? C3 Yes 0 Na License IVO D3[e <br />