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ORIGINAL STATE OV CALIFORNIA Do not frji in <br /> THE RESOURCES AGENCY <br /> e With DWR DEPARTMENT OF WATER RESOURCES No. 105885 <br /> i eE Intent No WATER WELL DRILLERS REPORT State Won No� _ <br /> erinit No or Date Other Well Na 'CS'* ..w <br /> (1) OWNER. (12) WELL LOG. Total depth-Ljb_ft Depth of completed weIL�rt <br /> Address from ft to ft Formation (Describe by color. character size or material) <br /> Citi 4 p $ — <br /> (2 LOCATION OF WELL rl It - YO <br /> ) (Sea instructions) e C7 — S <br /> Cminty Rwne>rs Well Number H 3 <br /> Well address if different from above u - e S <br /> Township - RaR$e Sectio $$ - ,- <br /> Distance from cities wads,railroads,fences,etc- I <br /> a lot 10 Jv c7 <br /> U <br /> (3) TYPE OF W OM <br /> New Well to Deepening ❑ <br /> Reconstruction ❑ <br /> Reconditioning ❑ - <br /> Hor3zontal Well ❑ -- <br /> Destruction ❑ (Describe - <br /> destruction materials <br /> procedures fa item 12` - <br /> (4) PROPOSED ii <br /> Domestic <br /> Irrigation ❑ <br /> Industrial ❑ <br /> T Woll ❑ <br /> Stec <br /> Municip <br /> WELT. LOCATION SKF'TCH Dther ❑ - <br /> (S) EQUIPMENTz (e) GRA y 1K, <br /> Rotary Reverse ❑ No size <br /> Cable g An, (3 1\ etr of hero It - <br /> Other ❑ Bucket 0 i[ ffo t -- <br /> (7) CASING INSTAL 1AD (8) ERFORA - <br /> Steel❑ pluaticp Ca r ` Type of p at ar a of scrco <br /> From To Dia Ga e_a F To " <br /> ft ft to Wall #t ft <br /> 0 1 `' <br /> (D) WELL SEALt ���� _ <br /> Was surface sanitary goal provided? Yes {i No f3 If yes, to dept- t <br /> Were stmtn scaled against pollution? Yes No Q Interval ft - <br /> Mothod of sealln QM ti+ Work star 19 fomplrt � to <br /> (10) WATER LEVELS WELL DRILLERS STATEMENT <br /> Depth of first water, If know*+ -- This well was drttlgd under mp lurfsdfctlon and Oils report is trite to the Seat of rnif <br /> Standing level after well completio knowledge and lidief <br /> (11) WELL TESTS SIGN>;n, ,` <br /> Was well test made? Yes'R No ❑ If yes, by whom? (`Veli Driller) <br /> Typo of test Pump 0 Bailer Cl Air lift 1W ]v�jy�F�n'r�rr�it 1�r..-pia :�ca(g�`6�e��icQ <br /> Depth to w�Ln/ter at start of test��ft At enol of test-31(- (Person,firm, t corporation) (Typed or printed <br /> i chaxgo�l gal/min after 3 tvn.rs Water tempera City �y�•(�,� � <br /> an4ysa made? Ycs 0 No [2If yes, by whom? GitY"a,. <br /> ectric log made? Yes ❑ No O If yes attich copy to thiv report lfcjqse No $ 3 Date of this report; <br /> own 108 (REV 7 7e) 1P ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />