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OCA, U <br />'7RiGINAL WATER WELL DRILLERS REPORT *�Do Not Fill In <br /> File Original,Duplicate and Triplicate with the (seat,„a Tore 7077,7078,Vater code) 1`r? 37295 <br /> REGIONAL WATER POLLUTION <br /> STATE OF CALIFORNIA <br /> ScaseWell No1*1 <br /> rROL BOARD dao- �� -- J <br /> ey}re}rleJr wse,brr) Other Well No.— <br /> 3 <br /> (i) <br /> OWNER (11) WELL LOG <br /> iName f.S /`I Q Total dcnri it Depth of compacted rdi ft <br /> Address / ♦ / ! y Fo,mae LOU Drtnrbr by,rofer,r6srerJn,Mt of,.elnFel awl rerrrsrrr <br /> it to it u <br />' (2) LOCATION OF WELL- <br /> G d <br /> r <br /> GaineyS� J u? (// ”Owner,namber ,!naw— <br />' R F D or Street No <br /> tv or� -. V, C, Z 2 37 C / <br /> WelC <br /> 7 <br /> (3) TYPE OF WORK (check): 5fh U o f _t' -"'7 <br /> New Vdix0e Deepensng ❑ Recondsnontag ❑ Abandon ❑ <br /> if•b&x&Wm xj,describe wwerml and procedure M Item 71 <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic 0 Industrial ❑ MumclpaI ❑ RotaryA&fe- <br /> Irrigatlon ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Dug WeU ❑ <br />' (6) CASING INSTALLED. If gravel packed <br /> SINGLE IQ�DOUBLE 71 Gage <br /> D,amcter from to <br /> I 2 aj f <br /> 12 wo of Bore It It <br /> to ft 9 Dtam <br /> 5~ <br /> Type aid e,u of shot or real nn= Stzc of s"'d <br /> Daasibe Ioaaa v a�•� � <br /> (7) PERFORATIONS: <br /> Type of perlorats wad <br /> Stu bir <br /> From It as f pal Perrow Rows f« <br /> Y <br /> (ti) CONSTRUCTION: -- <br /> ' Vat a earfsce sanitarT tai prew+ded? $Yes 0 No To what depth 2- fa <br /> t" 1 1 <br /> oat nay estate anted aprnst polivacon t Ya ❑ No If yes tote depth el strata <br /> From la ze Z Z ft <br /> ' Method Of Scaling Vert started 7" ! / 19" , completed <br /> (9) WATER LEVELS: 'WELL DRILLER'S STATEMENT <br /> ` Tbts tvrll tv i drilled wader 'my fwrrsdrrharr awd the$report Is <br /> twee to for best o <br /> wat obit&want wa first found -- /S{ ft my kwosvIedge and belkf <br /> as lewd befen prfanpni it NAME d C U r <br /> (r [peraon or corpcnt,un) (Typed ar pr,werl) <br /> 1.adtax level slur perforating <br /> ' Address e G sr <br /> (1 o) WELL TESTS: a I t7 <br /> Val s pomp Was mde? ❑Yet XNe It Ta,by whoa? IN / Y _ <br /> Ysabl, Rol/ran with Is draw dawn alter bra <br /> t - Fft arut.r "'' <br /> ON*emtwm of wager W"a cbea l aaelyats 0106414Pel `]Yes Ne License N4: I/Q 22 C r7'.- <br /> Dat ) <br /> _ �l -� — . <br /> T <br /> �. , _,__— i _r—81t 1'9 v_ WA wan a a.nor Cum S awo DWR ropse No tad (1tRV s 54 <br />