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STATE OF CALIFORNIA <br /> ORIGINAL THE RESOURCES AGENCY Do not fill in <br /> File with DWR DEPARTMENT OF WATER RESOURCES <br /> WATER WELL DRILLERS REPORT NO. 257301 <br /> !,I*,of Intent No. Slate Well Nooo <br /> Permit No. or Date 6 6Z z srj Other'.Well No.Gl wd&-02r 12 <br /> l) OWNED: Name ��Ev rZG`(`' U� t NC (I2) WELL LOG: Intal depth ft. Completed depth f 3'� ft. <br /> :kdtlress Z I C Ch k1 I NC 14 N10 <br /> from ft. to Ft. Formation(Describe bs-color,character,size or material) <br /> City fy C1- 'LIP 0 _ <br /> '2) LO ATIO OF WELL (See instructions): — 2G' i t- c_tc. Graf ftp li <br /> County f- �'`{4 Ll! f�/ Owner's Well Number <br /> Well address if different from above�5 E H 6'� �TCCe l"e r <br /> kislanct�froui <br /> ownship i N Range E coon 2J.5 <br /> cities, roads, railroads, fences, etc. F <br /> l7 — 2 <br /> (3) TYPE OF WORK: <br /> m New Well P�-Deepening ❑ C4 Ll - <br /> C Reconstruction ❑ — <br /> 4f SiTF AI �O Reconditioning ❑ <br /> 7a Horizontal Well ❑ <br /> ty Destruction ❑ (Describe <br /> destruction materials and pro- <br /> cedures in Item 12) <br /> (4) PROPOSED US _ ({ ' \�J) /� \ r1�✓ <br /> Domestic — ` V) 111 CJ <br /> rets Irrigation \,> <br /> �( Industrial ❑ s.`� �-J <br /> Test Well O ❑ e v <br /> RY Munici , ❑ \� — �� f\� <br /> .�� 0 er Ft 7'C ire( <br /> WELL,LOCATION SKETCH ') <br /> 55) EQUIPMENT: GRAVYGK: �r <br /> Rotary El Reverse ❑ No .^/ Siie' <br /> Cable ElAir ❑ et of bore <br /> t <br /> ;,.,Other [ Buck led from <br /> .. i i — <br /> (7) CASING INSTALLEIJ: (8) PE teel ❑ Plastic n e Ty of fnfT <br /> on ovr size of r O — <br /> From D' Cage or of — <br /> ft. f Wali t. size — <br /> w'qt-c 2a a.ozo <br /> 9) WELL SEAL: ,�[ C1Q = <br /> Was surface sanitary seal provided? Yes K\ No If yes,to depth ft. <br /> Vere strata sealed against pollution? Yes ❑ No X Irate fwI R. <br /> Methodofsealtng ce—to i a Work started 19 Completed 19 <br /> 10) WATER LEVELS: -3 WELL DRIL ERS STATEMENT: <br /> epthof first water,if known ft. <br /> C• This well was drilled under my jurisdiction and t report is true to the <br /> Standing level after well completion S -3c" ft. best of ruy knowledge and ix•lii'}. <br /> fl) WELL TESTS: �'�{ Signed e <br /> as well test made? Yes ❑ No W If,yes,by whom? 01"A <br /> t ell n e <br /> of test Pump El [Baiter 0 Air lift ClNAMT f�` i i NC f eF�cr f" ' � � S pi�-C-T-PZ" H <br /> ( o water at start of test ft. At end of test ft. �. erson,f(nn,or cn rationn)(Ty rLprinted) <br /> ,loge gat/min after hours Watertemperattire Address Ze Z2 L S <br /> heroical analysis made? Yes No ❑ If yes,by whom? L City 5;T���r �� �� QIP a 5 2�� <br /> ryas electric log made Yes ❑ No If yes,attach copy to this report License No. `' f 57 2C—'9 Date of t his report <br /> IF ADDITIONAL SPACE 1S NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br /> DWR Igo(REV. 12-66) 86 9&335 <br /> Q3 <br />