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f <br /> 1I V 7 1967. <br /> ORIGINAL WATER WELL DRILLERS REPORTA Do Not Fill In <br /> N9File Original,Duplicate and Triplicate with the (sections 7076,7077,7079,'Witer Code) 9 64382 <br /> REGIONAL WATER POLLUTION State Wel!No.1-Nil. � c <br /> STATE OF CALIFORNIA ,- <br /> CONTROL BOARD) No <br /> vet approprJalr number) j5 Other Well No.___----------_--------_____�-_ <br /> `-�-'-` '- <br /> O ER: (11) WELL LOG: <br /> / <br /> Name To[al depth 17-2-1 ft. Depth of completed well ` fr <br /> Addres Formation: Describe by color,cbn.rlrr,Ike of material,and rfruclurr. <br /> fr.to ft. <br /> (2) LO ATION OF WELL: <br /> Council er'c number,if any Ole <br /> — <br /> R.F.D.or Strttt ,• <br /> J <br /> (3) TYPE OF WORK (check): <br /> New well Deepening ❑ Reconditioning ❑ Abandon ❑ " <br /> u <br /> If abandonment,describe material and procedure in Item 11. " <br /> (4) PROPOSED USE (check): (5) EQUIPMENT: <br /> Domestic Industrial ❑ Municipal ❑ Rotary ❑ <br /> JAL. ., LIP� <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable I <br /> Dug Well ❑ " <br /> (6) CASING INSTALLED: If gravel packed „ <br /> SINGLE`l�al DOUBLE Gage „ <br /> •� r or Diameter from to <br /> From ft.to ft. Diam. Wall -i-8-re ft. ft. <br /> Type and size of shoe or well ring Size of gravel: „ <br /> u " <br /> Describe joint „ <br /> (7) PERFORATI S: „ <br /> u Type of perforator cased , <br /> Size of puforuiom in.,length,by in. <br /> From fe,er ft. Nrf.per row Rown per it. .. <br /> (8) CONSTRUCTION:y „ <br /> Zeas a .;rfaee sanitary seal prorided? ❑ No To what depth ft. <br /> u Were any strata sealed againtr pollution/??�����?0 Ya ❑ No If yet• as.depth of macs .. .. <br /> From It.co ft. 1 : .L ,r— <br /> 'dethod of Sealing Work started �. ` 19 Completed f9 <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> This well was drilled under my jurisdiction and this report is true to the best of <br /> Depth at which water was fiat found ft• my knowledge and belief. <br /> u 4' ndipg la•tl before perfonring ft. NAME <br /> ,e i<•el nicer perforating f[. (Pers firm,or�orpcu[,...a, ,YYGrd ur Dr.elrJi <br /> Address <br /> (10) WELL TESTS: <br /> C'at a pump[tat made? ❑ Yet O No if yes,61 whom? _ <br /> Yield: gal./min, with it. draw down after bet. [SIGNED]_._ _ ______.�_ _ __ ____ _-------- --. <br /> Wr t Driller <br /> Temperature of water Wet a thermal analysis mad.? ❑ Ya ❑ No License No.______-------___—---- _ ..... Dated-----------------............------........19_----.--- <br /> u <br /> R'ac$freer it log m.de of well? ❑ Yet ❑ No <br /> $702116-57 110M QUIN d SP o DWR 188 (REV.9-541 <br />