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ORIGINAL WATER WELL DRILLERS REP+..ttT Do Not Fill 11f <br /> Pile Original, Duplicate and Triplicate with the }sectionsygu, 7077, ID72iWnnrCode) No 56567REGIONAL WATER POLLUTION Add- as V 7 <br /> STATE OF CALIFORNIA sat< WrENo _ . P1�ZE�.� <br /> ONTROL BOARD No _ �I � F <br /> t Ph P 1 er number) (JL <br /> � ` ) OWNER: J ( 11 ) WELL LOG: <br /> Name ✓ / Total depth � O ft, DO of counpleted wall dood?y-O <br />� <br /> Address �� J Q �, . zjej= Mss IPA, Formation: Desrr/br by taint, rbnarfrc, <iu'of mrlericl, reel rlrvr(vrr. <br /> nen24? .c . - V fr. an J to 'e• <br /> (2 ) LOCATION OF LL: ­TO5� NOT OF <br /> County746[e rJ Owaer 5 number, if any— <br /> A. P. no or strNo. J " <br /> we <br /> 7it / 7Z <br /> Z7.2 wry „ ddd <br /> IN r u/ <br /> (3 ) TYPE OF WORK (check) :. 3 ., <br /> New well Deepening ❑ Reeondidoning ❑ Abandon ❑ to <br /> If abandonment, describe material and procedure In Item lt , - • <br /> (4) PROPOSED USE ( check) : I ( 5 ) EQUIPMENT: ; <br /> Domestic Industrial El Municipal ❑ Rotary <br /> Irrigation [3Test Well E] Other El Cable El <br /> Dug Well F1 <br /> ( 6 ) CASING INSTALLED: If gravel packed <br /> if <br /> SINGLE DOUBLE i Gap <br /> ,. <br /> Fromq matte from ., <br /> (� fr. to /00 is, Diant /x of <br /> of Bore fr. It .. ,. <br /> If 7 <br /> to IF <br /> Is To <br /> ft <br /> tto , <br /> To „11 FT do FTf <br /> dr <br /> 44 It If FT <br /> do <br /> Tree zed date of ghee or well ring !/A,aU size of gravel: �• <br /> Describe joint lux �— .. .. <br /> (7) PERFORATIONS: <br /> T,K of perforator wed <br /> Si2c of Perforation 'v., leexth, by iv „ <br /> From ft. an fr. Pnf, per row Rewe Per ft. <br /> to FT to 11 it to 14 If <br /> No it if 61 off 46 L <br /> IN ft <br /> do It IF 40 it 41 <br /> FT <br /> ( 8 ) CONSTRUCTION: f• <br /> Was a surface eaeltery sai provided? ❑ Yes ❑ No To what depth it. ,4 '• OFFN`IA-Le 11 € npa Y <br /> Were any feasts mated easiest Pollution? You 0N 'if yes, non depth of errata d <br /> „ <br /> From e ft. to / 0 0 <br /> IN <br /> Method of Stalin f <br /> Scaling Q n d r v Wnak a to /a7— Z� szo Completes <br /> od <br /> 19 �a . <br /> (9 ) WATER LEVELS: WELL DRILLER'S STATEMENT: <br /> Depth at which water was fimt found Thir well was drilled under my jurirdirt/on and skis report A true to thr berf saY fr• my knowledge and belief. f <br /> 5 ding level brfoto prcbruing f0• NAME t i ' <br /> Pg Ind altec ptef0nting ? • _ ,' Afar , d . • h1 . • i 1K. r < <br /> f'• ; fir a 'rterboi.uvel LA4Zi a7Fttd'ur.611h <br /> Address <br /> ( 10) WELL TESTS: vw., rr a e r44 , , <br /> I • <br /> . , ; ; TY • <br /> lea <br /> ?. <br /> Vim Pump tan made2 ❑ Y<e [3 No If yes, by whom? l <br /> Yuld: 1./min, with [$1GNED <br /> Y J Y <br /> ga ft. dnw Jew. .(ger Fre. "•--"--._..�.-.—�— . — — _..__ <br /> Well Dann <br /> Ttmeeraavt< a( wawr W» a chemical analysis made? ❑ Yes ❑ No License <br /> -._.......�__..__, 19._._., <br /> Was electric log made of well ? ❑ Yes ❑ No <br /> 57025 6-ay sans 0u N A seo DW R ISS (REV, s-nal <br />