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ORI3INAL � 'WATER (TELL DRILLERS REPORT � Do Not Fill hs <br /> File Original,Ouphcale and Tripllcale m1h the (seat+ono 7076,7077.7079,sinter Cade) N9 67179 <br /> / <br /> REGIONAL WATER POLLUTION <br /> STATE OF CALIFORNIA tt-1 � <br /> s <br /> CONTROL BOARD No / Other `Gell No____ /-I'- <br /> rnnrt approprlaJa number) <br /> t <br /> } OWNER. (11) WELL LOG. <br /> Name Totai depth D ft Deptj+of completed well � h <br /> I Address Formation, DsjnJhe by color,rharactrr,rise of maferluf,and ti rufivar <br /> fe <br /> (2) LOCATION OF WEL I�— <br /> CwtntY , owner—enber,ifany— <br /> l .+ <br /> 09, <br /> G z.. �.7. _ <br /> sr l <br /> I (3) TYPE OF WORK (check) - <br /> New well PO Deepentn6 L] Reeond+tsuneng Cl Abandon 0 <br /> If abandoumerlf,describe material and procedure tit Item I I <br /> (4) PROPOSED USE (cheek) (5) EQUIPMENT: -- <br /> I Domestic $3 Industrial ❑ Municipal ❑ Rotary — <br /> Irngation ❑ Test Well ❑ OtherCable Q <br /> Dug Well — <br /> (6) CASING INSTALLED, if gravel packed <br /> SINGLE® DOUBLE I-] Gage <br /> /p ar D,ameser from to <br /> From d it to (a / _fe �yf Diem wa1[ of Bore it ft <br /> Type and ata of thoe or wall r,nx <br /> Demnbe joins <br /> (7) PERFORATIONS <br /> Type of perforsto+used <br /> Size of parforatio.t <br /> From Ir to ft Perf per roo, Row,per it T -- --- —--- — <br /> I8 CONSTRUCTION <br /> was a+v rfaea+aoitasy teal provider'.! ❑ Yea 0 No To that depth it , I�rt�'RI r•1 ' <br /> were voy nrua sealed asalotc pollutwa} Iq Ye[ Q No if yes,nota depth of aerate 1 <br /> From ft to 6 it <br /> Method of Sealing Work+Farted 1 19 Completed <br /> (9) WATER LEVELS WELL DRILLER'S STATEi1IENT <br /> This ivell was drilled ander my Iurisdrrbon and ibis report is frur to the best of <br /> naprh ae which watts was Bae favad it my know edge id belief f p <br /> Standing feral beforQ perfarat+ng <br /> lana level after perforating f[ fVerr firm or eoegant+o�, S t 47 <br /> 00i <br /> Addreu <br /> {10) WELL TESTS• <br /> Woe a p+tmp tort mad,? ❑Yrs [] Na if Tee,by.thamt <br /> Yuld+ gal/min with it draw down after hie LSi4NLD] / k <br /> W e J 1lrllirr <br /> Dated__ _r 19-- <br /> Temperasup of nater <br /> Was a chemical analy++s mad[) �Yea C'} Na L1CCnsC I`IO _m -._ -- --- __ -.----....- ---.- a - <br /> yr'as e&atna Soh made of well} 0 Yes 0 No 69056 4 G9 DOM pUW Q SPO DWR 168 inp 3 541 T <br />