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-DUP WATER WELL DRILLERS REPORT � Do Not FAIn <br /> File Original,Nplicate and Triplicate with the (sections 7076,7077,7078,Voter Cade) l�? 37280 <br /> �E <br /> REGIONAL WATER POLLUTION 5tau Well No — <br /> STATE OF CALIFORNIA <br /> CONTROL BOARD No <br /> inert appropriate■ -I—) Otber Well N0....L«ml- /___......»- <br /> j <br /> (1) OWNER-NER- (1 1) WELL LOG. <br /> Name � ,t 2 i" ( _t,� • 'l- f Tan[depth /I .0 it Depth of completed we)1 / / it <br /> Address Z ��...►.`,.,i�l•��.�"�,� r+ Form.um Dr.rnbe by rotor,n6rertrr,afze o/neeler?e?,"d striertsre <br /> it to it <br /> (2) LOCATION OF WELL: i ''�'"�� ' <br /> Canty - Owner t number if nay— <br /> R P D or Street No • ( G 4. I I `.�'.+i <br /> - r _ <br /> (3) TYPE OF WORK (check). <br />' New well Deepenutg 0 Aeeondttsnnutg ❑ Abandon ❑ <br /> If abdndoutrsent,describe materfal and procedure to Iters 11 <br /> (4) PROPOSED USE (check) (5), EQUIPMENT' <br /> Domestic ❑ Industrial ❑ Mumclpal ❑ Rotsry r 0 <br />' Imganon`fZ] Test Well ❑ Other ❑ Cable E] <br /> Dug Well ❑ <br /> (6) CASING INSTALLED. If gravel Packed <br /> SINGLE 0 DOUBLE Ll Gene -._ _ <br /> or Dramettr from to �' <br /> From / it to i eft Main Will of Bore it it <br /> IJ ' � <br /> Type and urang of shoe or well os Sae of gravel <br /> Describe pint T��` 1 <br /> (7) PERFORATIONS: <br /> Type of perforvu,aged <br /> Sl7.t of perfanttaat in. lanxth by to iy� <br /> From fr to ft Perf per row ltowr per fe t <br /> (s) CONSTRUCTION <br /> Wu a surface enttary aa]provided? ❑Yes ❑ No To what depth .rte it <br /> Were any atnta sealed asueut pollntton? ❑Yes ❑ No If yet nova depth of airan <br /> From •it to it <br /> Method of Sealing Vail:nested 19 completed _ 19 <br /> (9) WATER LEVELS _ _ WELL ARII.LEA'S STATEMENT <br /> Tber turn tact drilled undrr my)urudretrox and this report is true to the best of <br /> Deptb at wbtch water wu fint fogad �a it my knpwledge dnd brluf <br /> oil ins level before perforating I• w ` *, 1 fc NAME <br /> Andtng level after perforating j, it {Person firm err corper.'o ) (I-),➢d m Fri-J94) <br /> t Address <br /> (Z o) WELL TESTS: _«�� <br /> EY <br /> Was■pump reit made? 0 Yet L1.No If To by whom? � <br /> with it draw down after brt [SIGNED] <br /> Yield gal/awe 7r11 Drltln <br /> Tea ,aware of water 'Vol•ehinol"I aaalynt mad6? ❑ Ya [bNe <br /> pc l.tcenx No—_� _—_ __ — Dated <br /> Wiff electric Salt made of well? 0 Yea b No 25669 4 54 nor.oU 104 Q 3ro DWR FORM No 2d6 (REV 3 541 <br />