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File Orlpal,Dupl€tate and Triplicate with the (Seetioni 7074, 7077 7078 evat.r Code) NY 76830 <br /> REGIONAL WATER POLLUTI N STATE OF CALIFORNIA State Well No <br /> tto <br /> CONTROL BOARD No ] Other Well No— <br />� art approQrir?r aambrr) <br /> ([) OWNER {11) WELL LOG <br /> N ime _ <br /> ro—.4,Z_/�-a _7 Total depth � 0G/ ft Depth of completed re[I f�J_ y _ it <br /> dJrt.ss Fi rm rtmn Urrertbe by color,eh.—H— sr.r of nrarmrl and ilr.rsare <br /> fr to ft <br /> i <br /> (L) L ATIO OF WELL <br /> l'+un[y _ _ r s number if anv— <br /> s[ F U e,r were N J <br /> (3) TYPE OF WORK (check) <br /> New well Deepening ❑ Reconditioning ❑ Abandon ❑ <br /> l f abandonment,describe materna!and procedurr in 1 tem 1 I <br /> (4) PROPOSED USE (check) (5) EQUIPMENT <br />' Domestic Industrial ❑ Municipal ❑ Rotary Al <br /> Irrigation ❑ Test Well ❑ Otber ❑ Cable ❑ <br /> Dug Well ❑ <br />' (6) CASING INSTALLED If gravel packed <br /> SINGLE-..DOUBLE i� Gage <br /> or Diamere- from to <br /> From fe to it Dim Wall of Boer ft it <br /> rf , <br /> ype and st-e of rhos or well r ng site of grarel <br /> Describe point + <br /> (7) PERFORATIONS <br /> Type of perforacer used <br /> Size of perforations sn length by in <br /> From rr to fr Perf per eon Row,per ft <br /> (8) CONSTRUC'T'ION <br /> Was a surface sanitary seal provided? 0 Ya No To what depth it <br /> Wcrr say acrata sealed Aguilar pollution' n ❑ No it yes nuie leech of strata At� -" <br />' From ft to4�1 it \ ♦ �� <br /> N �� y <br /> Method of Sealing Work started 19 Completed — ` 4- <br />' (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> Vit: well mai drilled under my Iurudiction and this report is true to the best of <br /> Depth at which water was first found it ray knowled and belief <br /> -d+ng level before perforating it NAME /, <br />' fine le.el after perforattrig fe I'lrrson term r surpc .nus, r ,.rd or pr,areil <br /> Address r <br /> (10) WELL TESTS <br /> � <br /> k <br /> alas a pump test made? C] Yes INA If yes,by who-iss <br /> Ymid gal/nun with it draw down:iter hra �7 Well Drdirr <br /> Temperature of water Was a chemical analysis made? ❑ Yea a L,Cense No � _ �L Dated ' 19 <br /> Vai electric log made of well? Q Yet a byo..a ey sant ClU1N A sro DWR ISS (REV 3 Sq) <br /> 1 <br />