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wrAT9 OF<CAU190FIN1A <br /> ORIGINAL THE RE50VRCRS AGENCY Do not fill in <br /> • File with DDR D9PARTMENT OF WATER RESOURCES <br /> �} WATER WELL DRILLERS REPORT No. 253285 <br /> ice of Intent N06 2$6-0 s State Well Na <br /> cal Permit N%or D2te Other VIW-n No !dam <br /> (1) awNivft dame r r � (12) WELL LOG Total depth�� ft Completed depth 3t� Ft <br /> Address <br /> from Ft to Ft. Formation(Describe by color,character,size or material) <br /> city, �- ZIP Q - ravn, S <br /> (2) LOCATION OF WELL(See instructions} x rot 5 ail <br /> County Ownars Wall Number — I Ll - G4R\ i L <br /> Well address if different Fr m above Z `TY'it1 C. A <br /> Township Olk Moog. 96AS Section 2 6�I <br /> Distance Frcm cities,roads,retie fences,e )- ^ 30 129L V'ct { GIclx <br /> A tJ (3) TYPE OF WORK <br /> !r New Well 2r Deepening ❑ <br /> 1 Reemtruclion ❑ <br /> Reconditioning ❑ <br /> Horixontal Well ❑ <br /> Destruction ❑ (Describe <br /> destruction materials and <br /> pro-cedures in Item 12) V <br /> (4) PROPOSED US <br /> Domestic <br /> [niga4an <br /> DO� � Industrial ❑ <br /> i Test well 0 <br /> 6+Itsntcr ❑ � O <br /> t 30 O er <br /> Wi{LL LOCATION SKETCH C lbe) <br /> {S}EQU[PME" 61 CNAV xIiolasy © licvusc El \ iVa <br /> Cable ❑ Air ❑ [ met oibo[e t <br /> other �' Bu ed from b <br /> 17)CASING INSTALLED (8) P =G) TISteal © Yiastra ( n t c Tyoon at sire of <br /> From D c.i. <br /> Gage or t <br /> ft E Wali tj t size <br /> 3d S ,o a -- <br /> go <br /> (s) WELL SEAL _ <br /> Was surface sanitarysealprovided? Yes lr No ❑ ifymiadeptU. & _ <br /> Were strata seakdagolnstpollutwn2 Yes ❑ No 0' intervalfL <br /> Method OfMaltug Work started l - 18 Completed-tel- 18 <br /> (10) WATER LEVEIS t-I WELL DRILLER'S STATEMENT <br /> Depth of first watrr,if iuwit <br /> Stand ng love]altorwelleamplettan_ �� -- ft- �� wellwas <br /> kna�$¢ rand l furisdiclioir and lhls report Is iron to the <br /> (11) WELL TESTS <br /> &*Dmharp <br /> well test made? Yes ❑ No� If yrs,by whom? Signed '/j /elt pri <br /> of test Pomp ❑ Bolter❑ Arrlrft ❑ NAME 41,4 5;7 .f! /46M/ <br /> h to water at stari of lest ft. At ead of tai It. (Person.(irr[r,ar twn}{x'ypa[i orpr(TtW) <br /> gal/miaaftax—hours Walettempemtirre Address f <br /> Chemical ana4iils oiade? Yes ❑ NoEr if ycs,by whom? 4'lty �{ ZIP <br /> Was eledriciogmade Yes❑ Nog" If ye;attach rn tothis report Iaceme Na- 4 3'z9z6— Date of this rc ort <br /> DWR Ias iRav 1:2�40 lit ADDITIONAL SPACE IS NEE1780, USE NEXT CONSSCIMVaLY NUMSBRIKM FORM 11 <br /> K 96333 <br /> ' F <br />