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tern Ungtuol u,iyu LaT11I19 IFIFWJ II iy WTIR Tile - — — _ <br /> REGIONAL (5.ctiaa,70-6 7077,7071 w.t.r Cod.) N° 4[] 3 <br /> WATER POLLUTION 3 V!J <br /> CONTROL ]BOARD No STATE OF(lwre s e�ropr7. CALIFORNIA � State Well No <br /> r <br /> Ocher Well No <br /> (I) OWNER + � V <br /> ' (11) WELL LOG <br /> Name r 1.A N � <br /> Toui depth a fr Depeh 6f completed veil <br /> cldress ft <br /> D Formation Darribr by rofor,rb.r.rtrr rite of tn.anal .od00 A. rtrwrrwrr <br /> ft ID ft <br /> f� <br /> (z) LOCATION OF WELL. � �� <br /> County Owner a number iF any— ��� <br /> a <br /> A F Q or Srrret No <br /> f <br /> CL <br /> 1f N <br /> (3) TYPE OF WORK (cheek). <br /> ' New well Deepenmg 0 Reconditioning © Abandon <br /> If abattdoRment,describe material and procedtare in Item 11 <br /> (4) PROPOSED USE (check). (S) EQUIPMENT <br />' Domestic d Industrial ❑ Municipal ❑ Rotary ❑ <br /> Irrigation [Test Well ❑ Other Cable Z) <br /> Dug Well ❑ <br /> (6) CASING INSTALLED If gravel packed ` <br /> SINGLE r7 DOUBLE 7 Gage <br /> From or D smetec from to — <br /> fc to it Dram m.q 6f Rare it it <br /> I <br /> 1 <br /> rpe and t.zr of shoe or well rin6 H� � Size of sra•el <br /> Ducrebe joint a �/ <br /> (7) PERFORATIONS <br /> Type of perforator used <br /> Size of perfoftnooe la length by <br />' From fr to f[ Perf per row Rowe per It <br /> 1 <br /> (8) CONSTRUCTION: a <br />' pia a surface uattary seal provided? ❑ Ye Dlo what depth ft <br /> Were any strata coiled agnott pollution? ❑ Ye Np If yet note depth of strara <br /> From <br /> it to � <br /> it <br /> Method of Sealing 1 murk started O L t i L <br /> _ 194-4 Completed Q esI 5-'l 19} <br /> (9) WATER LEVELS: WELL DRILLER'S STATEMENT ~ <br />' Depth at which water was Etna!gond It This well was drilled ander my jxrrtdtetton and this report is true to the but of <br /> "'.odic;level before pemy knowledge and belief <br /> rfaratlnj h NAME � A�C 6 <br /> .i <br /> admR level after psrfgratmR �'' fa <br /> I y fFrrwn Lim or earmrauunj f I yped or Dr+.sed) <br /> (r o) WELL TESTS Address <br /> Aska pump uta made? ❑ Yea No If yea by whom <br /> 4!d, ,tat/min with It draw down after hn [SIGNED) <br /> I <br /> Temparasurt of water r. Will Dr1NF/ r <br /> was a ehemtul anolyut made? El yes No <br /> Ltcense No DatedU „!9 S� <br /> rot tffetrie III made of well? ❑ Ye No 956119 3 as SOMOi11N Sri� 1 <br /> DWR FORM NO Z4f3 TREY 3 yLt <br />