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` w n A cn WALL �Jtt LLLLtCJ A -LP 7RT A •."' -` `'• • .n <br />File 4rlginat Duplicate and Triplicate with the (5-t-. 7076 •a-- 1078 'r.ter code) L� 6� 6 14 6 <br />REGIONAL WATER POLLUTION <br />STATE OF CALIFORNIA,, ��>/� <br />ScareWell Na_ _ <br />CONTROL BOARD No I �, <br />'lnrert rppropr-atr aam6rrl Q[lter Well No <br />(11) WELL LOG <br />Total depth it Depth of completed wtll <br />Formation Dnntbr by calor cb"Oerrr urr o1 matnaai ana ltruclur• <br />(3) TYPE OF WORK (check) <br />New Drell x Deeoentng ❑ Rctonaluornmg '] 2.bandon ❑ <br />If aaanaonment descrme material and brocedure m Item 11 <br />(4) PROPOSED USE ( check)(5) EQUIPMENT <br />Domestic [:]Industrial F-1Municipal❑ Rotary 17Ir_ .atfon�' Test Well FF1 Other r E Cable <br />Duz Well <br />(6) CArtySING INSTALLED <br />SINGLE�y--r ❑CUBLE _ <br />From o it fluor <br />If gravel packed <br />Geer J <br />or iif D"^1et er 4om m <br />V•'aIi of Sore ft ft <br />Type ena.�ze of slice ae n <br />X / <br />St.e of gr -eel <br />De.en he io.ne <br />(7) PERFORATION$ <br />Used Type of perforata- ed <br />Sly of usfecanoa- <br />.1 length b. .n <br />From fr r t <br />peri per row Roe,. per, ft j <br />E 92 <br />1 <br />(8) CONSTRUCTION <br />WSS a -arta" . atary teal provided? X -Yea El No To what depth D ft <br />Were any strap -e:fed 26,11, politinon? ['I Yea <br />❑ No If ret at. depth of -eras. <br />From it to <br />it <br />Method of Sealing <br />(9) WATER LEVELS <br />n.pth -t wh.eh ..,er w, 6r,t fogad <br />ft <br />Standing lend 6 -fore pertors,rpg_ _ _ .., ._ f, <br />Ling level after perforat-ng fL <br />010) WELL TESTS <br />Wer - pump tr+, meds? ❑ Yet ❑ No If ter b7 -horn? <br />Y,cld gal /m -a with it dra. down it., has <br />Temperature of water VVa.. rieemml aaalrsv made? ❑ Ye. ❑ No <br />Wit ci crtrne lox made of well? ❑ Yes ❑ No <br />Work rureed �� t9 Completed <br />WELL DRILLER'S STATEMENT <br />Thts well was drilled ander my lurssdaction and this report is true to the best of <br />my knowledge and beluf d <br />NAME /r4Lf�, l,l�ie��✓Ji���h il��f/�J.lF//, , <br />r� / fl'er arm yr �eorperavenl „ 17 d <br />yP•a orp Rer/. <br />Address ��/ <br />JWr ! 17rrfler <br />LLeense No _ _ _ _ _ _ _ _ _ Dated <br />671x= 4 67 6OM oU1N L SPO 1 DWR 168 (REV n 34) <br />