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� Do Not�P�[l In <br /> ORIGINAL A,�+���4'7lR1iR �+� D���+D45 REPORT <br /> F11e Original,Duplicate and Trlplieata with the (seeti.n.tete,tett,tete,W.rer Cede) ill u 55291 <br /> REGIONAL WATER POLLUTIOly - <br /> STATE OF CALIFORNIIA� � S� StateVFeUX0_ <br /> . ..,,._.�...« <br /> ' CONTROL BOARD No.- ! y <br /> --true dpproprYaf.swarbn) `�' Other WtA lYa-----••-•-. •.------_--- <br /> (1) OWNER: (11) -VEIL LOG: <br /> Name <br /> Towld=pth <br /> Ad �+ fe. Dspt6 of eomRlrud well <br /> s <br /> drea9 F.rmaeion:DrsRl[x by rvlor,rharenrr,rem of arfer[dl,.ail shrrinn. <br /> !e.to it. <br /> { (2) LOCATION OF WELL; <br /> �I County owner's number.If.eat— I <br /> R.F.p,ar Ssrret Na, ` <br /> !T'f <br /> Ica <br /> (3) TYPE OF WORK (check): <br /> r New weli'xl Deepsning ❑ Rexondiduadng ❑ Abandon ❑ <br /> t f obcxdonwrral,describe Inst ld•xd proredure fn l!rne]1. <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domeaeie M Industrial ❑ Municipal ❑ Rorazy X1 <br /> ItTigariou'❑ Tesr Well ❑ Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> (6) CASING INSTALLED: If grave!packed <br /> Lam;• .. _ <br /> SINGLEJ& DOUSI,h I Gide „ <br /> or Y7iamee.r d.w s. <br /> From [t_to ft. DI—_ Wall of Pore ft. ft. <br /> r .. �... <br /> L - <br /> 4 Type and airs el shoe of veli tLask 5im of An..ls - <br /> Dnnihe pane .. r. <br /> i (7) PERFORATIONS: — <br /> .. <br /> Ttro of prrf.ne.r med .. <br /> Siu Of_pedwLtioes in.,leu Ko,by <br /> t From ft.to ft. Par[.per rov k..-=pa.It. _ <br /> (a) CONSTRUCTION: - <br /> t Cyn.a eurfaea sanitary real pr.vided) ❑Yea GJ No To what d#pth <br /> wy asrau se.led agimt polnzLe.) KYa- ❑No H yas,slaw dwpsh of wars - - <br /> '�F'l�lw_�D_'M 7p ft. <br /> aylY <br /> * etho—•Q 'Sieg � ��J 1waek etareed •, •• If G.mplettd — 1s <br /> (9) WATER LEVELS: G? � WELL DRILLER'S STATLMENT: <br /> This wdl was dr lard vndrr way jwrirefi hP x an 1b1.1 rrporf true fo tbr1rel of <br /> < _Dcpth s trkieh ware,w1 fins found ft, ,try kr0 d �� <br /> �r �andina letd before per[waeiea ft, <br /> NAME <br /> s,asl Intal afar perfa..e.R [s. <br /> --- - _ Addms f <br /> (10) WELL TES'T'S: <br /> _ w..=pwop arts made) 0 Yea [] No It yon.aY wb*m r <br /> d <br /> d. <br /> _ rid, !t.d <br /> r..ldsn1_/.v:.. d— we art fir.. ESsassaol._ — <br />� _���....... Wru pati.. —.._....-.�__...•--.................. <br /> r ,TC-4-urlw of w.rrr Was a thaminl analysis enadd) 4 Y. C3 N. 1-iCeryse hyo.__..____..,....•... Dated.,..•.��-__._. <br /> r 'q's rlernie lepp e.Wr{f-.IiT• ❑Ts ❑Nr .vozs a-er■sir iiYl)e G ern - DWR 100 [REV.9.84) <br />