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' ORIG4NAL p WATER WELL DRILLERS ROPRT Do Not D11 In <br /> File Original,Duplicate and Triplicate with the (Sections 7076 7077,7078 Water Code) t"1 N O 5 5�?T6 <br /> REGIONAL WATER POLLUTION <br /> -ON'rROL saARn No <br /> STATE OF CALIFORNIA State Well No _ if <br /> rr epproprralr number) , j_ Other Well No <br /> (I) OWPNE (11) WELL LOG <br />' Name Total depth 7b fr Depth of completed -ell ft <br /> Address117 Formation Dererrbe by color charartrr aur of tnatffsA cad rfractstre <br /> 4L Midge ft to it <br /> (2) LOATION OF WE ,Z c� <br /> County ' Owner t number if any— 0 T <br /> It F D or Strer o <br />' r <br /> 0 <br /> 7v o <br /> (3) TYPE OF WORK (check) <br /> New well 1I Deepening ❑ Reconditioning ❑ Abandon ❑ i! x t <br />' <br /> If abandonment,describe material and procedure in Item I I <br /> (4) PROPOSED USE (check) (5) EQUIPMENT: <br /> Domestic Industrial ❑ Municipal ❑ Rotary <br /> Irrigation ❑ Test Well ❑ Other ❑ Cable ❑ <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed <br /> t SINGLE W DOUBLE Gage — <br /> Dumerrr f om to <br /> From ppftt to it Main Wall of Bore ft ft <br />' Ty pe and nae of shoe or well ring Size of gravel <br /> Dacr:be Twat <br />' (7) PERFORATIONS: <br /> Type of prrfwmt,r aced <br /> 512 of perforations m length by ta, <br /> From ft rn ft Perf per row Row. <br /> per ft <br /> 1 <br />' (8) CONSTRUCTION: <br /> Was a surface sanitary teal provided? ❑ Yet Q No To what depth ft i <br />' 6!"11- Ls. <br /> E ONLY <br /> Were any strata sealed agaraac pollution? 51 yet ❑ No if yes note depth of strata <br /> From ft to ft <br /> V d a <br />' Method of Sea1mg Work started G l9 G c Completed _ ` 19 a <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT <br /> This well was drilled under my lurtsdiction and this report rs true to the best of <br />' Depth at which water was fiat found It my k7lovle;dy and belte J <br /> drag level before perforating ft /f �{ <br /> ding level after NA � 7 <br /> perforating ft <br /> (Yui n him Or wipe rain I 00��'T 7D oT fr / <br /> Address ( <br /> t <br /> (10) WELL TESTS: <br /> Was a pump test made? ❑ Yes ❑ No If Te[ by whom? <br /> Yield gal/min with ft draw down after his [SIGNED] <br /> Well Driller <br /> Temperarure of water We$a chemical anal Tats made} ❑ Yes [] No License No — Dated , )9 <br /> War electric lox trade of well? ❑ Ya ❑ No A <br /> 57025 6 57'JOM OVIN OsPp ` I [7WR 188 (REV 3 Sa) <br />