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ORIGINAL WATER W r,LL J)KTLLJ,Kb KEYUK 1 <br /> ' file Original,Duplicate and Triplicate with the (Sections 7076 7077 1073,'Warier code) N? 55306 <br /> REGIONAL WATER POLLU'T'ION State Well No %` . — �? <br /> CONTROL BOARD No STATE OF CALIFORNIA � r <br /> sort.pproprf.te uasabrr) 5 Othet'Well No 5 - r r <br />' (1) OWNER. (11) WELL LOG <br /> Name a yj/ J i Total depth -2 it Depth of eemplrted .cell _ /} ft. <br /> ,kddress � Fnrmanon Dese-be by color rhar-Iff sizeof mi.rnul 4nd itrertrre <br /> r <br /> It to ft <br /> (2) LOCAElolz" <br /> N OF ELL. , <br />' County � r-/ Owner s number If,nv--- <br /> R F D or Site No�7 K- t <br /> 42 <br /> Y <br />' (3) TYPE OF WORK (check) <br /> New well Deepening 0 Recondsuurnmg 0 Abandon El <br /> if abandonment,describe material and procedure in Ilene 11. z <br />' (4) PROPOSED USE (cbeck) (5) EQUIPMENT• 2'Z <br /> Domestic 0 Industrial F1 Municipal 1:1 Rotary <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ — <br /> Dug Well ❑ <br />' (6) CASING INSTALLED If gravel packed <br /> SINGLE Z DOUBLE Gast <br /> o Diameter from TO <br /> From t;'!- to 3 ft D,am tCaEl of Bore it ft — <br /> 7 ype and nze os,hoe or well nag f^� size of grovel <br /> Dem she Sotos <br /> (7) PERFORATIONS <br /> 1 Trpe of perforator used ^ <br /> SIZe of perforations in length by In <br /> From ft en It perf per row Ron,per ft <br /> i <br /> (8) CONSTRUCTION: <br /> Was a surface sanitary seal provided? 0 Yea 0 No To what depth Et <br />' <br /> Were any strati sealed'goose pollution? (X Yea 0 No if yea mote depth of strata <br /> From rt to i�7 it <br /> Method of Sealing marl:started �p��, 19�o Cump'e ed <br />' (9) WATER LEVELS: WELL DRILLERS STiTEMENT <br /> / <br /> This well was drdleJ under my lurisdretson and this report is trNe to the best of <br /> Depth at which water wes first found J� ft my knowledge and belief <br />' nding level before perforating ft NAME <br /> ding level after perforating ft tP,non nrr t wrpc 'nun t I vprd ur C—teJi <br /> Address <br /> (10) WELL TESTS. <br /> 19V.i a pump test made? 0 Yes 0 No If yes,by whom? <br /> Y,eld <br /> gal/wo with ([ draw dors afar hes Well Dra? <br /> Temperature of water Was a chemical anslyess made? 0 Yea 0 No License No _ Dated _ , I9 <br />' VP's electnc lo;made of well? 0 Yee 0 No 07025 4 !Y 7oM QUIN A SPO [)WR 188 (RIeV 3 Sat) <br />