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Al. f WATER WELL DRMLERS REPORT Do Not Fall In <br /> )NTnROL <br /> nal,Duplicate and Triplicate with the (sections 7076,PM,7678,vratar Coda) N9 55296 <br /> NAL WATER POLLUTION State�Ge11 No.zN DoE-Z6 <br /> 4e BOARD No STATEOF CALIFORNIA — ------ <br /> wt epproprlefr ariabrr) �/z C-r Other <br /> (1) O (2 I) WELL LOG <br /> Name -- _ Total depth jwjL> 10P f Depth of completedwell _-1 t <br /> .rte <br /> Addres5 v7 rii L y � Forma<rua Dr vrtbr 6y o'o: •bireC Cr,tl:!JI e.n ttrttlarr <br /> it to tt <br /> e7 <br /> (2) LOCATION OF WE L <br /> Count) Qwaer a slumber of say— <br /> A F D or Sweat No 7i <br /> _ 2 <br /> r � <br /> 1 <br /> (3) TYPE OF WORK (cbecA): <br /> New well ❑ Deepeatng ❑ Reaandtnontng ❑ A,b2adon ❑ 0 <br /> it abandonment,describe material axil cedure in Item 11. <br /> (4) PROPOSED USE (cbecA)• (S) EQUIPMENT: <br /> Domestic ❑ Industrial ❑ Musucipal ❑ Rotary ❑ e t' <br /> Irrlgatlon 9 Test Well ❑ Other ❑ Cable <br /> Dug Well ❑ <br /> (6) CASING INSTALLED. If gravel packed <br /> SINGLE N 00UOLE cafe <br /> or Diameter from to <br /> From fr to it Dtam V.11 of more it fr <br /> Type arid s+ac of that or well rams !yL x e is Sue of Eraval <br /> ?h•cnba Sant 1-13e -,"� ---- -._-_ <br /> (7) PERFORATIONS: <br /> Typo of perforator and <br /> S17-e of rforat+om leaItth by m <br /> From t r Pert per row R.—per it <br /> (S) CONSTRUCTION: <br /> Was a+tar°ace saattarr seal prmded? ❑ Yes ❑ No To what depta <br /> Were may mimes sealed against pollutma? EVIX I] No if Ya more depth of strata <br /> From fe to it <br /> Merhod of$eallag Work acatrad y 19/a Corom[ored t1 19,s <br /> (9) WATER LEVELS: 451-15— '+ WELL DRILLER'S STATE-M&NT <br /> That well-a as drdled under my ;artsdtc!tosr and tbtt report is trste to the best of <br /> Dep.h at wh.ch water was tint fogad It <br /> amy k kdAw and brlte f <br /> dtas levl before erforating NA4 <br /> 1 1 t y <br /> amu level alter putoradwg it f Porton h m err�wr r�on1 <br /> Address 1 <br /> (I 0) WELL TESTS: <br /> We-a pump mat mode? 0 Yea Cl No If 7w by whom? <br /> Yield pal/num with it draw down aftrr hn 4 <br /> Well DrlB[n � - <br /> Taanporature of water Was a ehest+eal malyus made? ❑ Yto ❑ No ! <br /> Ltcenx No._----- -----.. _ --_ Dated_ - <br /> -h <br />