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ORIG:"NAL. WATER WELL DRILLERS REPORT Do Not Fgu In <br />' File Urlgmal,Duplicate and Triplicate with the . (Sections 7076,7077 7078,Witter Cade) N? 53179 <br /> REGIONAL WATER POLLUTIONState Well No_ <br /> CONTROL BOARD No STATE OF CALIFORNIA / y <br /> (115197`1 rppro¢r(a! !fr number) 1, s / r(/ Other Well Na_ _ <br /> OWNE = (11) WELL LOG. <br /> Name , <br /> Total depth it Depth of completed well it <br /> t Address 7 G Formation Dnmbe by color,rb"Oet r,lszr of m4ierul and itrurturr <br /> �] it to r ft <br /> (2) LOBATION OF WELL: <br /> 1 County " t, Owner s number if ant— <br /> R F D or Street N' <br /> r <br />' (3) TYPE OF WORK (check) ¢ <br /> New well Deepening ❑ Recondiuontng ❑ Abandon ❑ ""7 Oel <br /> . r _ <br /> If abandonment,describe material and procedure 1n Ittm I1 <br />' (4) PROPOSED USE (check) (S) EQUIPMENT. <br /> Domestic ❑ Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irngatlon JZ Test Well ❑ Other ❑ Cable <br />' Dug Well — <br /> (b) CASING INSTALLED. If gravel packed <br /> SINGLE14 DOUBLEfi 1 <br /> or Diameter from to <br />' From it to it Dsgm Wall of Sore it f7` <br /> Sl <br /> Type and size of shoe or wel I ring ' L��' 2 Ssze of gravel <br />' Deacrtbe Joint <br /> (7) PERFORATIONS. <br />' Type of perforator wed <br /> Size of perforation$ in,length by in <br /> From it to it Perf per row Row•per it <br /> 1 <br />' (8) CONSTRUCTION ' <br /> +� T t <br /> C�ML USE <br /> Was a surface sanitary sell provided? �1 Yes {] No 7`o what depth '7 � ft <br />' Were any strata sealed against poilucton? ❑ Ya ❑ No If yes,nom depth of strata <br /> From (t to £t <br /> Method of Sealing Work started lad — I �' f mpleted `r t9J <br />' (9) 'WATER LEVELS: WELL DRILLER'S STATEMETNT L <br /> This well was drilled under my)ur$sdichon and thisrF-), <br /> t is true to the best of <br /> Depth it which water was first found ���� It vty knowledge and belief r' / "'l �c ,Standsng]eve]before puforsvngft NAME { a At 4i- Zls�' -( <br /> �dinot ievel 60 it � l' tion h 4t r0lPt[�punJ K 7�prd or rnatedi <br /> 'elAddress t _ <br /> �(10) WELL TESTS. <br /> Was a Pump test made? ❑ Ycs ❑ No If yes by whom? '-'Y ' <br /> � _� fire. <br /> Yield gal/mm Wath ft draw down nicer hrs [SIGNED) <br /> ...syy(((fff {V ➢rilirr Y <br /> Temperature of water Was$chemical agaiysls wader ❑ Yes 0y No License No �C � ' �� Dated • , 19 <br />' WAr e-eccrsc IoR made of well? ❑ Yes 0 No <br /> 57025 41 57 aOM OUINA SPO 101 DWR 188 (REV 3 Oql <br />