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ORIGINAL W H 1 ZZIL W ZLL ,IjA11.Lr.Ma Azru t i <br /> File Original,Duplicate and Triplicate wlih the (Se«,ons 7076,7477 7079,mater code) N Y 55305 <br /> REGIONAL WATER POLLUTION State Well No <br /> CONTROL BOARD Na STATE OF CALIFORNIA _ <br /> ref rpproprfarr asimbrrJ Other Well No <br /> V <br /> OWNER. (11) WELL LOG. <br /> e r yTotal derth VZ) f Depth of tompleted wcll � � ft <br /> ress 1 1 f�O Z Formation Dnr+rbr by rotor,r6�rarrrr,u;r o/ norm✓1,r ed vire slurs <br /> n A to 4L ft <br /> & <br /> � � <br /> (2) I,QCATION OF WELL <br /> Coo nY3owner, w 4� v <br /> sy. number if any— <br /> R F D or Str t N , <br /> v - LL 2 > <br /> 4 -- <br /> ' (3) TYPE OF WORK (check) y / <br /> >v <br /> New well Deepening Ll <br /> © Absndaa ❑ <br /> ff obandonment,drrcrrbe-material and procedure in Ite»a I I Jli 1!J <br /> (4) PROPOSED USE (check) (5) EQUIPMENT <br /> Domestic Industrial ❑ Municipal ❑ Rotary IN <br /> Irngation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE: DOUBLE:L Gant <br /> or Diameter from ro <br /> From +I l ft to ] ft Dtam VCaEI of Bare it <br /> ft <br /> Tree and site of shoe or well ring �� Size of gravel - —�"'- <br /> Dne-Ib.,wqt r� - <br /> (7) PERFORATIONS <br /> Type of perforator used <br /> Size of perforations to length by in <br /> From ft to ft Perf per row Rrwt rer ft <br /> (8) CONSTRUCTION <br /> Was a surface sanetary seal provided? Q Ya ❑ No To what depth ft <br /> Were any strata sealed against pollution? Yes ❑ No If yes note depth of strict <br /> From rr to �..7 ft <br /> Method of Sealing Gc�J<Y Work maned C_ ��� 1941/r l_omple ed 1." <br /> ' (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> This well was drilled milder my )urmsdlctlon arrd this report/s true to the bess of <br /> Depth At which water was first found ft my knowledge and bel&f <br /> 4smg level before perforating (s NAME <br /> #g level after perforating ft ill non drm or wrperrtiu !iArd or praerej <br /> Address <br /> 0) WELL TESTS <br /> Leas a pump test made? ❑ Yea 0 No if yes by whom? <br /> Yield ;lel/man with ft draw down after his [STONED] <br /> Wr rfrlrr <br /> Temperature of water Was a chemical analysts made? ❑ Yet ❑ No License No _ Dated .. ,19 <br /> C'as electric[am made of well? ❑ Yes ❑ No <br /> l7aYa a 37 eoM qutH A a7'O pWR lf3 fj (REV 3 541 <br />