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ORIGINAL WATER WELL DRILLERS REPORTA Do Not Fill In <br />' <br /> File Original,Duplicate and Triplicate with the (Sect,oas 7076,7077,7076 'cater code) l�9 67146 <br /> REGIONAL WATER POLLUTION State Well Noll S7.1'E-a 0 <br /> BOARD CONTROL B STATE OF CALIFORNIA r� `C <br /> No�_ <br /> 'Insert appropriate nnotber) Other Well No <br /> I) O R• (11) WELL LOG <br /> Name XTotal depth 1—Z, V it Depth of eompleced well f <br /> Address Formation Drscr,br by color cbnarin size of materfaf and struriure <br /> r <br /> it to it <br /> (2) L AT ON OF WELL <br /> r <br /> Coisnty OCroce s number if anv— <br /> R F o Str <br /> T <br /> ' I <br />' (3) TYPE OF WORK (check) , Q <br /> New Well ks Deepening ❑ Reconditioning ❑ 4bandon ❑ �} <br /> if abandonment,describe material and procedure to Item 11 �� <br />' (4) PROPOSED USE (check) (5) EQUIPMENT: <br /> Domestic ❑ Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation Test Well ❑ Other ❑ Cable j� <br />' Dug Well ❑` Of <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE DOUBLE1 Gage <br /> Dlamecer from to <br /> From fc to it Dram Wa11 of Bore it it <br /> R 1IZ 91 r.z. <br /> Type and ore of shoe or veli I g / Size of gravel <br /> OX <br />' Describe toot _ <br /> (7) PERFORATIONS <br /> ' Type of perforate-wed <br /> Size of perforations a length by <br /> Froomo <br /> Froft to Jrr iPerf per rosy Ra-s per it La <br /> (8) CONSTRUCTION. <br /> Was a surface sanitary seal provided? )LYts ❑ No To what depth Q it <br /> Were any ntata sealed against Polluttoo? ❑ Yes ❑ No if Yee unit depth of strata <br /> ' From ft to ft <br /> Method of SealingaZy Work started '^' ]9 Completed L 39 <br /> ' (9) WATER LEVELS- WELL DRILLER'S STATEMENT <br /> This well was drilled ander my jurisdiction and Ibis report is true to the best of <br /> Depth at which-ate,was first found it my knowledge and belief <br /> Stands' level beforeperforatingft <br /> g - -•- •- —."Z NAME/��!'i ���1 /e�✓- ,�/��� Il/ �i- ��..�.s'/���-� <br /> ' ung level after perforating a7 it / ,f�'crs firm f.rfcorpe,ananl_ /�� YTl ped or y,ted) <br /> Address ✓[ / "� Y <br /> (10) WELL TESTS• oe <br /> �+y <br /> Was a pomp test made? ❑ Yet ❑ No If yet,by-hems <br /> Yield gal/Imo with it des-do-n [after brit [SIGNED] <br /> i/��/� rpr j Drfrfer ' Lr+� <br /> Temperature of water Was It chemical analysis made? ❑ Yes Cl No License No _ — Dated_ _ _ • 19 <br /> ' War electric log made of-e111 ❑ Yet ❑ No 67025 6 57 SOU QUIN A SPO II DWR 188 (REV 3 Sb) <br />