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STATE QP cALIPORNIA <br /> ORIGINAL TNN!r-SOURCHS At9>NCY Do not fill in <br /> • File with DW R DEPARTMENT OF WATER RSSOURCES <br /> WATER WELL DRILLERS REPORT No. 253284 <br /> me of[*teat No., 5 a Stan Well No. _ — <br /> Permit Na or Date Other Well Nu <br /> (1) OWNER. N.r !�)a+f i r" cCl ' e Ihv5 -The- (12) WELL LOG Total depth _To fL Completed depth^'�It <br />' Address from ft to ft Formation(Dewnbe by color.character site or matedaD <br /> --� Q �- G <br /> (2) LOCCA,.T�I�ON F WELL(See imtructions) 1 a 114 ti <br />' County-� Owners Well Nnmber —Z — rq ILI r-L G <br /> Well udrlress if diffe=t�from above 'rte I a <br /> Towiaship _ Hauge ScclioR - G. It <br /> Drs forms chic;nmdsy audnad;fie etc 3 Q,r V, <br />' N (9)TYPE OF WORK <br /> >7 New Well eD--pona-g (3 <br /> Reconstruction ❑ <br />' Retosrdlhorung Q — <br /> Hodmmbtl Well ❑ <br /> Dedrarchou 0 {Describe <br /> destru tion materials and pro- <br /> cedures in Item 12) <br /> Z (4) PROPOSED U5 <br /> Dornesstla <br /> Irrigation <br />' Industrial ❑ <br /> Test Well ❑ <br /> -- O <br /> I -"-Boo" o er <br /> WBI,L i.QCA1TON 5lClrl'Cli <br /> ibe} r <br /> (5) FQUiRtdl r GRA CR. <br /> Rotary❑ Revusa ( N. <br /> y <br />' Cable ❑ Air C3 $ bow 1 <br /> t3thar I Huci e 1 am a <br /> (11, CASINGRMALLSD: <br />' acet ❑ Plaahe 2 t TY of o orsir-of Q From T i Gage ar <br /> ft i Wall t sire <br />' Lw O.0zo w <br /> (9) WELL SEAT... <br /> WataorFeeessaitaryeea)provid4W Yea Ig` No❑ fly.%todepth 2— fL W <br /> lvexesrrata rmled avimt polluiia"? Yea 0 N00- Iatenai IL <br /> method cFseahng Work stated <br /> (10) WATER LEVELSe �r WELL DRH LER'S STATEMENT <br /> DepthoffttAwaW.irlvsawsr �� -J Z umsrondW g level aRru weii completion S-S�• bat f am�y Imamdle ge�r,try f:lrtrdierion aytd tMs report is true to the <br /> (11) wELL TESTS st nw f <br />' a:rotdl test made? Yrs © Pio!� If yr;by whom? I' IW d�� W <br /> of tot Pu-P lJ goner❑ Air Iift 0 NAME f� <br /> towattaatstartofhit It Ateadafted IL !� R soma )(Typedor ) <br /> tschuM gat/snivafter lawn Wgierk-renntum Address <br /> Cbeaic4.xjy&mede? Yes❑ NO) lEyet,bywhom? Cly - <br />' Watd=t3de log trade Yes Q No 1r If attach m this t l:r=a,N. � Date of this report r� <br /> oWit ilia my i2-sm IF ADDri'ONAt.SPACE IS 13MORD. Usg tog=CONSOCUTIVIRLY taUMBEWED FORM � 9aa55 <br />