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ORIGINAL.. � � WATER WELL DRILLERS REPORT Do Not Fill In <br /> File Orfoinal,Duplicate and Tripiieata with the (seetsona 7074 7077,7079,macer code) tai M N9 55 <br /> REGIONAL WAITER POLLUTION Scace Well Na ����__ <br /> 0_r>NTROL BOARD No STATE OF CALIFORNIA <br /> 0 e>rrnlrer) / ` other Well No <br /> (1) OWNER (11) WELL LOG, <br /> Name Total depth, 0 fr Derth of completed -till it <br /> Address Formanon Defcrrbr by color cbatrrter,size of material end irrartare <br /> it to ft <br /> o 2- <br /> (2) LO ATION OF WE Z <br /> PCounty Owner r auraber sf ane— J <br /> P. F D of <br /> Scree- <br /> IF <br /> G <br /> �tQ d <br /> (3) TYPE OF WORK (check). <br /> New well 1% Deepening ❑ Reconditioning ❑ Abandon ❑ ` <br /> if abandonment,desrrrbe matertol and procedure rx item 11 <br /> (4) PROPOSED USE (check) (5) EQUIPMENT: <br /> Domestic W Industrial ❑ Mumc?pal ❑ Rotary X <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> z <br /> (6) CASING INSTALLED. If gravel packed <br /> SINGLE IN DOUBLE- Gage 1 <br /> Dume[er from to <br /> From ft to ft Duro Wail of nor. Er ft <br /> 1 ype and s,re of shoe or it ung G �� S.ze of gavel <br /> Dewnhe Joint_1y - <br /> (7) PERFORATIONS <br /> 'rape of P.rfarator aaed <br /> Size of trerforatsout in length by ra <br /> From m r[ Perf per row A.ws per it <br /> (8) CONSTRUCTION <br /> Was a surtace sanitary seal provided? ❑ Yea ❑ No To what depth it s <br /> si 34. <br /> Were any strata sealed agunst pollution? Yea ❑ No Sf)ver note depth of ate.ea <br /> From rt to it - - — <br /> a <br /> Method of Sealing Work started ` �7 19(, C.Mrde cd <br /> a <br /> (9) WATER LEVELS- WELL DRILLER'S STATEMENT <br /> That well was drilled under my lunsdretiox and tbts repar+is true to the brat of <br /> Depth ar which water was first found it eery knowled It belre <br /> mg levet before Jxrtoritmg ft + <br /> NA <br /> .lsag level after perfantsag it - {�'er n firm ser~ser py,tauunJ ; { yp or teefl <br /> Address t i A <br /> (1 a) WELL TESTS. 4 <br /> Was a pump mat road*? ❑ Yes ❑ No If res,by whom? <br /> yield gal/min with it draw down attar hes I$IGNED] _ _ _ __ -- — <br /> iPerr Defiler <br /> Tesnper,seure of water Was a chemical aailyua made? ❑ Yea 0 No LlCessse ND- _ Dated_ _ _ _ —.19 _ __ <br />