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' ORIGINAL WATER WELL DRILLERS R�ORT Do Not Fill In <br /> File Original,Duplicate and Triplicate with the • (Sections 7076,7077 7076,Water Code) NO 78061 <br /> REGIONAL WATER POLLU'T'ION � <br /> CONTROL BOARD No <br /> STATE OF CALIFORNIA StateVvdlNo <br /> — <br /> rrt appropriate number) 6_ Other Well No <br /> (1) OWNER (11) WELL LOG <br /> Name <br /> j Total depth ft Depth of completed well ? ft <br />' Address [ Formation Derrrrbr by color,cbaror,rr,iris of rneerrml aid st.ucluer <br /> ft to It <br />' (2) LOCATION OF WELL <br /> County tier t number if anv— <br /> R F D or Srrert N sJ, <br /> rt <br /> (3) TYPE OF WORK (check) <br /> New well Deepening ❑ Reconditioning ❑ abandon ❑ 'fj _ o <br /> I f abandonment describe maternal and procedure to Item i I <br /> (4) PROPOSED USE (check) (5) EQUIPMENT: f <br /> Domestic 9—Industrial ❑ Municipal ❑ Rotar} ❑ ` / <br /> Irrigation ❑ Test Well [:] Other ❑ Cable <br /> Dug Well <br /> (6) CASING INSTALLED. If gravel packed <br /> SINGLE DOU13LE Gage <br />' ar Demeter from to <br /> F <br /> From (c to ft Dsam all of Bore it ft <br /> 3p <br /> Type and s,xe a(shoe ar well ring S,ae of gravel :1V' <br /> Describe joint IJ,,- <br /> (7) <br /> (7) PERFORATIONS: ' <br />' Type of perforator used <br /> S1ze of perforationsto length by <br /> From ft t,, ft Pert per row Raw.per It <br />' (S) CONSTRUCTION <br /> Was a surface satntary seal pmndedi ❑ Yea No To what depth g <br />' Were eay atraca sealed aguaat pollution? ❑ Yq [k No If yea note depth of strata <br /> From ft to <br /> ft <br /> Method of Sealing 7 Work started l9 Completed (9 6 <br /> (9) WATER LEVELS: WELL DRILL 'S STATEMENT <br /> G) Tits well Was drilled under my)urrsdiction and tins report is true to the best f <br /> andtbeluf <br /> Depth at which water Wes 6rrt found ft my knowledg <br /> s <br /> e-ndsag level before perforating ft NAME of <br /> tax level after perfora ling J ft Ptr n nem crauu� ,I tPtd pr,nerd) <br /> Address <br />' 10) WELL TESTS: � __ -.'._ /t <br /> Was a yvmp test modes [] YerAND If yes by whom, <br /> Yield SIGP3Eu <br /> xal/siva with fr draw down after hn [ _,-1pr17 pts der <br /> Temperature of Water Was s chemical analysis made? {] Yes 0 N License NoJ Oated �"'71 h , s 19 Lr <br />' War elcctnc lox made of well? <br /> [] Yet � No /a��a j <br /> 67025 a 57 QOM 00IN SPO y } DWR 189 (REV 3 94) <br /> Y <br />