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ORIG1N"'L WATER WELL DRILLERS REPORT � Do Not Frll In <br /> l� <br /> File Original,Duplicate and Triplicate with the (sections 7076,7077,7078,Water cede) ? 64397 <br /> GOther Well Na <br /> IONAL WATER POLLUTION STATE OF CALIFORNIA� l State Well No <br /> ) <br /> VNTROL BOARD No <br /> "�rrrt appropriate member) — <br /> ) OWNE (11) WELL LOG: a <br /> Name Tota)depth .1 xft. Depth of completed well ft <br />' Address `� Formation Diatribe by mlor,eborecter,size of metriaf and itruriure <br /> fr to ft <br /> rt <br />' (2) L TION OF WELL- <br /> count ace a number if an. 27 <br /> — <br /> R F D or StId 4 0C <br /> reit <br /> (3) TYPE OF WORK (check) <br /> New well ❑ DeepeningA Reconditionmg ❑ Abandon ❑ <br /> if abandonment,describe rttaterul and procedure sn ltetn 11 <br /> (4) PROPOSED USE (check) (5) EQUIPMENT- <br /> Domestic ❑ Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irngatlon,�Test Well ❑ Other ❑ Cable <br /> Dug Well <br /> (6) CASING INSTALLED, If gravel packed <br /> SINGLE DOUBLE ❑ Caen <br /> or Diameter from to <br /> m f to ft Dram Wa11 of Bore it ft <br /> 1 <br /> Type and size of shoe or well ring Size of gravel <br />' Describe Cant <br /> (7) PERFORATIONS: . <br />' Type of perforator wed <br /> SIZC of perforations s4,length b <br /> FromIY - <br /> fr rn ft peri per row Rows per ft <br />' (S) CONSTRUCTION. <br /> Was a surface unitary seal provided? ❑ Yet l] No To what depth ft <br /> Were any strata sealed against pollution? Q Yet ❑ No If yes note depth of strata <br /> From it to ft <br /> Method of Sealing Work started 19 <br /> 9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> This well was drilled under my lurrrdtchon and this report rs true to the bort of <br /> at which water vas first found ft <br /> >:Fay knowledge and beluf <br /> Nor <br />' Standen levl before erforattng <br /> NAms VALLEY W i=,: 1.'d-,1— D'M'LLIIVG & F <br /> IsnA level after perfo-snag ft (Ytr m u �orperat�un I l),Ard or prated) <br /> Address <br /> (10) WELL TESTS: <br />' <br /> V.,a Pump test mades ❑ y" <br /> 0 No If yes by whom s <br /> Ytrld [SIGNED <br /> Ra'/stun with it dray dawn atter hra // W rffrr <br /> Temoerytare or warm Was a clit—ul an■lyasa mad.? lel Yes © No License No /.�/S: J w ��� Dated � �2-- , I9 <br />