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ORIGINAL W H A Lt iI W I.LL A11tALLimno istrzrUild to • "'• a •rr 116 File Original, Duplicate and Triplicate with the (secnom 7076, 1077, rove, Ibacer code) lv O 55305 REGIONAL WATER POLLUTION State Well No._, (:L.,,,_i`,,....:`...'"..:.'rT CONTROL BOARD xD. STATE OF CALIFORNIA ^ / pass! of 'J Fcs Other Well No..._........._... ..........._._.. ..... 1 . ...... ( 1 ) OWNER: ( 11 ) WELL LOG: Name j, e Total depth t/,f U fr. Depth of completed well Id (r Address /N i' / lac �/ O 2. Formation: Describe by color, rhuarlrr, Nese of merrcWl, .eJJ Ormfurr. '1"lb • .fi /�i'L �f"l /� / ;1 ..✓ n ft. to 4L ft. [I; C - ( 2 ) LQCATION OF WELL : / 9 / '� d'i : County Owned number, if any— / 'f •f * / C1L* ft. P. D. or Sa t N aP ; b/ :1 . . ; ./,�,, , a ,P. .. � ) .. �A 1 411i 4IZ441A 2L FiN 63 3 ( 3 ) TYPE OF WORK (check) : 9 / New well Deepening ❑ Reconditioning ❑ Abandon ❑ IL If abaxdonmex6 describe material and procedure in Item 11 . L 1 U " ( 4) PROPOSED USE ( check) : ( 5 ) EQUIPMENT : Domestic Industrial ❑ Municipal ❑ I Rotary Irrigation . C] Test Well ElOther ❑ Cable E] Dug Well ( 6 ) CASING INSTALLED : If gravel packed SINGLEDOUBLE % INIt•• .• Diameter from From 41 n. to �J fa. Z Diam. Wall of ear. Jr. .. .. 14 do I do 11 IN I p to ON Type and nae of threat well rine, Size of emus): -- - Du<:iM It ON t to ( 7 ) PERFORATIONS : to .. Type of petfunmr wed .. .. size of perfonaiotr From ft, In ft. 'Part. per row Rua'a per ft. . . 11 It ( 8 ) CONSTRUCTION : .. .. Wit I surface artistry said provided ? ❑ Yea ❑ No To what depth fit „ Were SAY strata Foaled asaimc pollution? tQ Yes ❑ No If ter, note depth of strata ., I. fNot topr - ft From I' a c y •.I tt. .. t No to 41 ON do 41 Method of Sealing [! rxa,:„ Work said /C . 3/ lqs, completes ( 9 ) WATER LEVELS : WELL DRILLERFS STATEMENT; This well was drilled under my turisdiotion and this report is true to the best of Depth Ft which water aI first fopna - it, my knowledge and belief. dint level bdrc opnfor ting 1st NAME I AF level after pedorscia ; IF, (Person, firm. or Creep 0 , 1 sped „r printed; Address ( 1 D ) WELL TESTS: was a pump teat made) Q Yes ❑ No if yet, by whom ? �/y•�^�/ � Yield : Wal./xde. with Et. draw down after hes. (STONED) ......... . ... .. . . .... .. l ..... .7 ....._......"............._..._......._ We ertler Temperature of water Wit a chard analysis made? ❑ Yea ❑ No License IN........................................... Dated......_...................... .... ...... ..., 19..... ...... W„ A«nic log Ad of well ? 0 Yes O No 07021 9-17 FOM QUIN A was D W R 168 (RSV. 9.54 )