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"E <br />'ORIGINAL WATER WELL DRILLERS REPORT *TDo Not Fill lie <br /> Hie 0riplaal,Duplicate and Triplicate srllh the (Swi.a.a 70716,707:1.7074.Par6r cede) lr? 37297 <br /> REGIONAL NATER POLLUTION State Well No— <br /> TROL BOARD No STATE OF CALIFORNIA <br /> 1 glrefrlstt o+t.brr) Other Well N.,;—Y-- <br /> OWNER. <br /> orG Y-- --- <br /> {1) OWNER. , (11) WELL LOG <br />'Name 1� / , Tonal depth J?.ft Depth of completed well _ is <br /> Address Formation Drsr 4e by color cberartr+ some of taatnld.and reruns+e f/ <br /> / _.. it to it <br /> (2) LOCATION OF WELL: t 7 <br /> eonatTS n tr 1 -71 Owner a nttmber,a!aar— / N ! / �a;/S <br /> IL F D or Stern No U d U <br /> 2 <br /> Ol- <br /> _ _31 t ��- <br /> (3) TYPE OF WORK (check): <br /> New bell K Deepening ❑ Reeondst-onang © Abandon ❑ <br />'11 rbondoMMsmi,describe weerLl wind prmeedsasee is Inas I] <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic $ r-1Industrial Murnc:pal ❑ Rotary a1❑J\ <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable <br /> Dug Well ❑ <br /> (6) CASING INSTALLED: If gravel packed <br /> 1 SINGLE DOUBLE f.1 iLr'69t I]tamerer from to <br /> rDlll j-t to r 3 fe y Dum !• rt—�dl o[Seer it it <br /> t <br />' Type Sad"m of shot or well ring Sue of gravel <br /> Den gibe joint <br /> C / <br /> (7) PERFORATIONS. <br /> Typo or perforato-said <br /> SrYt of nova <br /> w 1,11 <br />' From it is A it Perf per row Rewe prr it � <br /> 72 <br /> nr" t�� <br /> •. "� t'r I .l t t <br /> (B) CONSTRUCTION: ' <br /> Via•savf&W mmtary sal proTtdrdj N(Tes ❑ No To what depth ti „d fl <br /> Vests my strata sealed axatan poikottonJ ;K'Ym ❑ No If Ter,ban depth of strata <br /> From / is . 2-2 it <br />' Method of$ealu:g C a s e 21 a?u pork stut6d Tu 1 3 u Cowpleted J'✓ f 1e <br /> (9) WATER LEVELS: WELL DRILLER's STATEMENT <br /> T6n turn am drilled Mader ray Jurisdiction and!bu rrport is true to the best o <br /> h at which water was fins found it my kMow4ed8 fad li k1 <br /> h r" } <br /> aaa k.d bsf6n perferattaa NAME T w r C <br /> J41adrnx Iswd situ ytrforsuox it Yerw ran or earPLrallox 11!Y►ed car Jnwtrdl <br /> Address <br /> (f 0) WELL TESTS: to C J <br /> was a pump was mads? ❑Ta XN6 It ran.M whom? <br /> Todds ad/own with if draw Clown after lin I51G1MED]�/, �^well ValHrrrr, / J� <br /> ' Tompmre otaat water wan a chemical 41aalTaa m4d6) ❑ Tea Na License No.41 2--2-; ~C 17 Dated_ <br /> tlC a+elsttr.e lie made of well? 0 Yea WN. *54164 4 4141 SOW OU-14 0 aro pWR Forast No 246 rR[Y 3 54 <br />