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His WgInal,Duplicate and Triplicate with the (sections 7076,7077,7072,'Water code) N V 7 6 Q Q O <br /> REGIONAL WATER POLL TI N State Well No <br /> CONTROL BOARD No <br /> STATE OF CALIFORNIA } <br /> I, V <br /> � err!epproptlels>sa,abss) Other No "`'- <br /> (1) OWNER , (11) WELL LOG <br /> NlmcA , <br /> Intal depsh �✓ It Depth of completed well It <br /> iSj CESS I"Irm ttson Descrrhr by color,cherar4r,n_e of waeerier end stracturr <br /> ft co Ec <br /> (l) L ATIO OF WELL <br /> C lunea <br /> Y w T r number if anv— <br /> ' st F t1 ur ztrert N I <br /> Q7 i <br /> (3) TYPE OF WORK (check) <br /> New well Deepening ❑ Reconditcontng ❑ abandon ❑ <br /> If abandonment,describe material and procedure in Item 11 D <br /> (4) PROPOSED USE (check) (S) EQUIPMENT <br /> ' Domestic 0 Industrial ❑ Munfclpal ❑ Rotary 2�' �—� <br /> Irngatfon ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed <br /> SINGLE —DOUBLE i� Gage <br /> U-ameres from to <br /> From ft to Et Dtam Wall of Bore fc IT <br /> 2,z - <br /> Wqwp.and size of-hot or Weil r n; Stzt of gravel <br /> Desenbe iotnt <br /> (r) PERFORATIONS <br /> Tirpe of perforator toed <br /> Size of mrforonons In length by in <br /> ' From fr to ft Perf per rota Rows par it <br /> (8) CONSTRUCTION: <br /> aPu s surface sonnies red prov-dsd? ❑ Yes &No To what depth G s <br /> Were any ttrsts sealed agunse pollution? p ❑ No if rn 09"depth of strata -��r`a . -: <br /> From cc to ft ` <br /> i <br /> Method of Seating Work stsreed 14 Completed <br /> (9) WATER LEVELS: WELL DRILLERS STATEMENT N'" <br /> ' <br /> This well was drilled under my)arudretion and this report is true to the best of <br /> Depth at which water-as first found ft ,ny llitnowled and belief <br /> -drag level before pceforattng ft NAME / <br /> Lag 14ve1 alter perforating tt t,Htrmn,arm r torper.uo�, T e1 or pnntsd) <br /> Address <br /> 0) WELL 'PESTS: <br /> a pump use made! ❑ Yes l�No !f 7a,67 wbliTT <br /> Yields gal/M. with It ilea+dove after hes �/ Well DrrHer <br /> Temperacore of Water Was a aheasical anslyns madai [3 Yet o Lleense No I/Q(/�� - 172 Dated _ , 19 <br /> 71'as electric log made of well? [I Yea o <br /> ' 97020 a 77 eqM 7tJSN 4 3Yo DWR 188 (REV 3 34) <br />