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File Original, Duplicate and Triplicate with the +� (seaeam 7074, 7077, Tort, meter Code) .... ~ N 00 5 53 0 6 <br /> REGIONAL WATER POLLUTION <br /> o <br /> STATE OF CALIFORNIA State Well No....1..9_.:'..c._,:_ __ ..: r- .r <br /> CONTROL HOARD No. �1 �' <br /> ' '$are ePbrppems number) <br /> ( 1 ) OWNER: //`t� J / J ( 11 ) WELL LOG: <br /> Nameya'LvEs� �Pe Total depth IN ft. Depth of completed well it, <br /> Address ii /�,j good Formation; Darrribr by rotas liste er, site of inerntaf, and ro-rnnrr• <br /> o ro;tO4 If <br /> /✓- <br /> god <br /> ( 2 ) LOCATION OF ELL : <br /> Countyr�,<d. Ojiaiwn umber, if sag - / <br /> R. F. D, or Sire No <br /> Not <br /> god ate Gy <br /> -G <br /> or <br /> do <br /> �/. <br /> .. 8 <br /> ( 1 ) TYPE OF WORK ( check) : ,y'q - 9/ P <br /> Deepening Reconditioning ❑ Abandon ❑ it /.i7/ <br /> New well IN <br /> IN <br /> If abaudiNgste t, describe material and procedure in Item 11, _NOW /d 2 ' <br /> (4) PROPOSED USE ( chec/% ) 1 ( 5 ) EQUIPMENT : 12. 2 <br /> Domestic f� Industrial ❑ Municipal ❑ Rotary - 2el'' ,. lye .. /� •- �� <br /> Irrigation C) Test Well El Other 1:1 Dug <br /> ❑ 6 <br /> Dug Well ❑ Ft <br /> It <br /> ( 6 ) CASING INSTALLED : If gravel packed <br /> SINGLE DOUB LE L: Gate • .• <br /> Diameter from <br /> From 0 rt. to 93 fe. clam wail of Bore ft, fat. .. .. <br /> ON <br /> IN <br /> Type and siaa of shed-o-qr �well ring /1K, c of initial: .. <br /> Ductile hand o!4' joy .. , . <br /> ( 7 ) PERFORATIONS : .. .. — <br /> TIa of pedoraaor meth .. <br /> P. <br /> NIN <br /> Size of parforati9m in., length, by In. .. _.. 1 <br /> From <br /> fr. to h. Pert per row Rower per it. .. 1 Note <br /> ON <br /> do 1 44 to IN IN If at <br /> it It do 11 to go is do <br /> ( 8 ) CONSTRUCTION : .. <br /> Wu a surface ranteorr rad provided ? D Yet ❑ No To what depth ft. 11 ,• <br /> Wen any stages soiled s ima polluciool la Yn Q No If yes, nate depth of strata <br /> From 0 ct. �h 4 ft. .. .. v • • . , <br /> Method of Sealing ,Ly,r,ry Work sterted i Ip/ o . Completed god- _ / 71; lado <br /> ( 9 ) WATER LEVELS : WELL DRILLER'S STATEMENT: <br /> / Thir well war drilledunderroy inrhdioliou and this report is true to the best of <br /> Depth at which water wn first fina d �� ft. my knowledge and belie). <br /> " ••Wing ltvil before perforating ft, NAME <br /> Jing level after perforating ft. il'rnon, term• or curpe atiun . i I or t'r'+/edl <br /> Address <br /> ( 10 ) WELL TESTS : <br /> Was a pump lose made? ❑ Yes ❑ No If Vers by whom? <br /> Yields ad./min. with ft. draw down afpr his. I$IGNBe J._........................................ " I W 11 orll .• .... ... ...-..........••...-..._.-...... <br /> Temperature of wares Was a chemical analysis made? Cl Yes 0 No License Not.............. . ...:. .. .. Dated......_................ . . I9 <br /> Wit deente log made of wall? 0 Yes 0 No 17929 0-97 IOU 9nln 0 aro D WR 188 f aEY. NIN <br />