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1110 Urlgmal; Duplltale and Triplicate with IN (Sections 7076, 7017, 7004 , Water Code) N V r7 Q Q r' <br /> REGIONAL WATER POLLUTISIN State Well Na.._.......1_._-.0....J...V__....._..i.. .. <br /> v�J— STATE OF CALIFORNIA �� / µt , // y_ <br /> CONTROL BOARD No I' �,� - I Other $II No,...`. ,[,..:. . ...�._ ""' / p <br /> ' fell epprop7/ape Smaller) ,... .........(....4.rt1 <br /> IN <br /> ( 1 ) OWNER: ( 11 ) WELL LOG : <br /> Name �� / ,,{ <br /> !CC �.1 ..�' 11/.d' J 7enl Borth / f� tri-/ ft. D< Jt of con,rl< <d II J aN few <br /> Address Formnsuns Describe by color, n <br /> ober a7 , size Not ,n•,neriel, end Nrer)mre <br /> fe, to it. <br /> ( 1 j L NATIO OF WELL : <br /> msy IN ClIvalffilumbra, if sn <br /> IN <br /> R. F. D, or Street / <br /> NJ <br /> Zr� Sn v a ;o e ./ <br /> ( 3 ) TYPE OF WORK ( check) : IF <br /> New well, Deepening ❑ Recondidoning ❑ Abandon El ' <br /> if abandonment, describe material and proredure in item 11 . D " <br /> (4 ) PROPOSED USE ( check) : I ( S ) EQUIPMENT : <br /> Domestic 0 Industrial p Municipal ❑ Ao[ary <br /> Irrigation ❑ Test \Xrell ❑ Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> ( 6 ) CASING INSTALLED : If gravel packed <br /> SINGIN..DOUBLE [] Gare •. <br /> Diameter from o <br /> From fc. to k. Dam. Wali of eon (q it. ,. <br /> tel ' so — ,. .. <br /> 41 NJ <br /> NJ 14 <br /> Type and site of shoe or well clog Site of gravel: - .. .. <br /> Dreeribe !Dint .. ,. <br /> MAIN <br /> ( 7 ) PERFORATIONS ! <br /> Ty" f preference d <br /> SIZe of perforation$ <br /> in., length. by in, 11 . <br /> From. (r, to ft. praf. per Rows pa ft. „ No <br /> NJ it <br /> ( 8 ) CONSTRUCTION: T <br /> 1 Vca <br /> War a senate sanitary nal pnvidtd? 0 Yes ®rNo To Nettle depth ft, � 1 •• . . • . '�. � C�� C <br /> Wen gay masa oiled against pollutionpe a ❑ Ne IE Y•y ooae depth of snau .. ., +I+ ,�7, <br /> w� <br /> From rt. ( it. •• E e <br /> Method of Sealing Work startsa 14 1 . c9mplaed glr <br /> ( 9 ) WATER LEVELS : WELL DRILLER'S STATEMENT: _. <br /> This well was drilled under my Jurifdiction and this report is true to the best all <br /> Depth at which water wit fire%. toned ft* my krcowled and belief, <br /> IN Iding level before perforating ft* NAME / . 'e <br /> 1, ling le:d after per[ar Ing it. (Yert r urn DNN I r td or primed) <br /> Address (.-' <br /> ( 10 ) NVELL TESTS : / <br /> Wal a Plant test made? ❑ Yee Wir if Tea, by whom} <br /> ao <br /> Yields gal./min. with it. draw down after fire 1$IGN ] ....._.Q ...........t'.. y .. Well Driller <br /> •__.. .............:...._....._.. ......... <br /> Tanpeeatare A water Wet a chemical analysis made) ❑ Yes o License No..,l9I_JJa mTl Dated....I...................... ._. 19 <br /> Wit electric log made of wan ? 0 Yes Moro $7034 4.47 nN 001N 4 spa D W R 188 ( REV. 9.64 ) <br />