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1 <br /> r 7r,A I� r�pT CHECK <br />' ORIGINAL WATER WELL DRILLERS REPORT �T'Bo xor37296 <br /> x1>+t� Ix C <br /> Hit Original,Duplicate and Triplicate with the (Sect ,ors,7017,7071.Qatar Cade) ,Ir\? 3 ` rG 9 V <br /> REGIONAL WATER POLLU'T'ION <br /> $theWell Ve No N <br /> TROL BOARD No STATE OF CALIFORNIA.,. other Will 71n...L! <br /> rr}rafr,.re.rrbrr) <br /> (1) OWNER (I I) WELL LOG. <br /> _ t <br /> Nagle /� w _ _y ' 1 T6ta1 depth <br /> 410 ft Depth of completed well LJ <br /> it <br /> Address a 4 V Formation Drrrnbw b)color rberrr,rr s."of rerlerfrl,red?marline <br /> ft to ft a 5' <br />' Lc 'z C a /Y - - c <br /> T �G <br /> (2) LOCATION OF WELL. <br /> CottatT Str 77 " .J e -" r ,Owner s number tf a..— /a �+� i 0(J <br /> llw P D nr Street No Or <br /> s <br /> (3) TYPE OF WORK (check): <br /> Newwell,K Deepening ❑ Recondtnoorng ❑ - Abandon ❑ <br /> if abtnrdonment,desenbr m0erul sed procedure in Item I1 <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic ja Industrial ❑ Municipal ❑ Rotary A' areo K Irrigation ❑ Test Well ❑ Other ❑ Cable ° ❑ <br /> Dug Well ❑ <br /> t <br /> (6) CASING INSTALLED. If gravel packed <br /> SINGLEZ DOUBLE[I G. f ` <br /> Drameter from to <br /> ITfc to ft J DrsD,.. i 2; ee m) of 1I*- ft ft _ <br /> ,-- ti '-w..-- <br /> a t er <br /> e <br />' TM and size of ohm or well nns r Sue of s:aeel <br /> (7) PERFORATIONS: <br /> Trpe of psrf--rued <br /> SIZe Of <br /> awhmtjb to <br />' Fran it to ft Pat row Rowe fu <br /> (8) CONSTRUCTION: .. r <br /> Vis A surface ruutary teal pro.tdedt X Yet 0 No To what depth — <br /> wwo say strau sealed agwast pollattonP ❑ Yes ❑ No U Too,sets depth of rtests <br /> Frowna, t, ft to 2I.ft <br />' Method g Sealing G a •rock started 7"L If '('0 compteted <br /> (9) 4ATER LEVELS: WELL DRILLERS STATEMENT a+ <br /> f 7'brr well wee drilled under my )urridiction and tbo report is trete to 11"belt o <br /> ILMLb at whtth water vas Ent fused / !t my haowled a And belief <br /> lot ItVw before perforauag ft NAME LTA ` 7 <br /> rtdrna I+rel aftae perlonnaa !t tso;�firm yr c"mrstwnl +7 yotd or►r..red) <br /> 1Addr«a <br /> (lo) 'WELL TESTS: [� f • 1 41 <br /> im a pmap are made? ❑Yes No If To.by wkamT <br /> Yaddt KNI/Imo with ft draw dews Alter hra feU DrlIg" / 9 <br /> ' Tempmaturr of water was a ebeaaral UNITsia on"ot C] Yes Ne Lte"se No y/� 1 z 2 — -`�S l7 Dated z <br /> 1l� �•^ � . 19`! <br /> w• t__ t_..� <br /> 4..f-.113 f-1 Y.. td N. *sure 1 a.wr ou 1 sro OWR FORM NO 24E inKv a 5• <br />