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_ I1 <br /> orzrGINAt f- �A srArE OF CALrFORNrA L Ca, ION NOT GH�� 39_614 <br /> File(410al,D DW&fe a^d,Tllpfleale wish V�k � V DF-P,e,RTMENT OF PUBLIC WORKS <br /> DIVISId OF WATER MOURC6 <br /> P o BOX 5079 DIVISION OF WATER RESOURCES <br /> • s SACRAMEN7o S CALIFORNIA ' <br /> Do Not Fill In <br /> WATER WELL DRILLERS REPORT Swe Well No____�- _ w _ <br /> .3 <br /> (Sections 7076,yo»,fare,Wester Code) Ot ear Well Nof`7 v— -i-: <br /> Reglan__.—_— __ TM_ �3'# <br /> (1) Driller: � ;`� (2) Proposed use or uses (check) (3) Equipment used <br /> Name_o,/� '�"y *" �_ �_ Domestic1�]r' Munic,pal ❑ (check): <br /> Address frrigation [] Industrial ❑ Rotary ❑ <br /> LJ Domestic and Test well <br /> ---� .-a--- [] Cable <br /> License r_._Classlfecation—l '_ Irrigation ❑ Dug well ❑ <br /> Other______ Other_ .—.__ <br /> Owner• t nn _ <br /> Name__ �r�'�%r!YL r'�%—r __ �._ _ (4) Type of worts (ch ck) <br /> Ad \7/- r�� s^x '�41�.— ____ �__ _ New we]! g;�— e Reconditioning of well ❑ <br /> Deepening existing well ❑ <br /> (5) ViTeII log: <br /> Total depth of well _ft Give details a£forma[�ons penecra[ed,such-Is silt,peat,muck, sand,gravel, clay,shale,sand- <br /> stone,hardpan,rack Include size of gravel (diameter) and sand (fine, medium,colrse),color <br /> Depth From Ground Surface of material,structure (loose,packed,cemented, soft,hard,brittle) <br /> --ft to_ f'1 _ft. <br /> a <br /> > r <br /> Jr J. J• <br /> 011 <br /> If additional space Is required,continue on DWR Form No 246 Supplement, and attach to respective report copies <br /> (6) Casing left in Well: <br /> LENGTH DIAMETER SINGLE DOUSLE WELDED LITS PER FOOT OR SEATING BELOW <br /> FT INCH S OT14E� GAGE OF CASING GROUND SURFACE FT <br /> Type and size of shoe or well ring j�We[dcd )alnts es ❑ No <br /> D W R FORM No 246 'REGIONAL WATER POLLUTION CONI ROI, gOARID COPY <br />