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IGINAL ITER WELL DRILLER$ REPO Do Not Fill In <br /> I Original,Duplicate and Triplicate with the (s.cti.o.7076,7077,7078,W.t.e Code) N U 5531k, <br /> :GIONAL WATER POLLUTION <br /> :.oNTROL BOARD No. State Well No----._-_,,r <br /> STATE OF CALIFORNIA �j •� F'"� --- - <br /> ---'PProPri•se...her) /� / <br /> 1 Ocher Well No-------------- <br /> (1) OWNER: e <br /> (1 I) WELL LOG: <br /> Name /��U� / Total depth� f ft. Depth of compies,d well /"710�4 ft <br /> Address Format;on: Dn Mbr by color,cben•eler,Size of r•etri•l,•.d st+.rt.v. <br /> ft.to ft. <br /> (2) LO ATION OF WELL,//f <br /> Co..,) Owner's number,if any— 2- <br /> R.F. .or Sue . 31yy <br /> 4 <br /> A' G <br /> (3) TYPE OF WORK (check): <br /> New well X Deepening ❑ Reconditioning ❑ Abandon ❑ l <br /> if abandonment,describe material and procedure in Item II. 141 <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic .g Industrial ❑ Municipal ❑ Rotary <br /> Irrigation ❑ Test Well E] Other ElCable <br /> Dug Well ❑ <br /> (6) CASING INSTALLED: If gravel packed <br /> SINGLE DOUBLE Gage — <br /> „r Diameter from to <br /> From fs,to ft. Dum. \tall of Bore ft. ft. <br /> hype and nr of shot or veli nng - S,re of gravel: ,. <br /> D—,ib,ioiot W05-44- <br /> (7) <br /> 05-4L(7) PERFORATIONS: —m-y <br /> T,pe of perforator sued <br /> Size of perforation, irs.,I.ng,h,by is <br /> From p.rf.per roc R per n. <br /> (8) CONSTRUCTION: <br /> Was a —fact,an;tary,cal provided) ❑ Ya ❑ No To wh.t depth ft. .y <br /> Viae stayrtrau,er)ed.gun,t pollusionP �Ya ❑ No 1(yo,..s,depth of ni�rata ,. ~��` <br /> From ' <br /> ft.to ft. .. <br /> Method of Sealing G�'rx,L a-,� Tork started19 <br /> Completed <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Dtp,h.,which w.,er v„firs,food // ft This well was drilled under my jurisdiction and this report is true to the best of <br /> my knou,Ied e, sad belief. <br /> �rand�a gIvd before pcforz,ng ft. 1 <br /> /) <br /> .,g level afro perforating NAME <br /> ft. i <br /> .... V" <br /> yr pn rrdi <br /> Address e f+ <br /> (10) WELL TESTS: <br /> 'War a pump tat made) ❑ Ye, Cl No If ya,by whom? <br /> Y..Id: gal./mio. w;eh ft. draw down after hrs. [SIGNED]..._...._.._.__....-.._ -_. - - _ .. ._..._.--------------------- <br /> ____ <br /> T.mperatnre of w.,.r Waa Well D Wer <br /> a chemical analysis mads) ❑ Ya ❑ ":o <br /> ' License No.. ... _... Dated....__... - 19 <br /> U'n elatric Io1 made of we117 ❑ Ya ❑ No <br /> 67C16 657 60M CuIN A SPO DWR 188 (REV. 9-941 <br />