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QUADRUPLICATE S I A t h OF CAI 11 Olt\[1 DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLE-KIO,lN REPORT <br /> Page—of \ Rrfrr to lnttiucNari I'rniplilrt STATE WELL NO/STATION NO <br /> Owner's Well No r My !r s "2 1 No Q Q 0 O C <br /> V LATITUDE LONGITUDE <br /> IJ LtP 11'otk 8�gan,;.,�-,moi .. ,��r Ended; " �' �6 <br /> Li ll POrl lilt AgCITCV APNITRSIOTHER <br /> $�PiLI tit No P(,rtnit 1?Ite <br /> GEOLOGIC LOG IVLLL OWNER <br /> ORIENTATION (✓) �_VERTICAL —HORIZONTAL —ANGLE _(SPECIFY} Nd111C 4- <br /> DRILLING 4 _ Tr Mai)tt]�T A(1C1reti5 L <br /> DEPTH FROM METHOD FLUID rI`,. 1��", !T^ <br /> SURFACE DLS[,111011i I ' <br /> F[ to Ft DLtr r ibb ❑at(i ml Brenn Sim{ ii (t[ CITY STATE ZIP <br /> WELL LOCATION <br /> I I Addt e55 -- <br /> C ttv <br /> Countv <br /> f <br /> APN Bonk y Pag,P P it a.] <br /> Township Ratig(, SCc,tion <br /> tt1Fs" I I C !A r ) Lcltltud(, I I NORTH I�c�alg�thtcle VIES' <br /> DEG MIN SEC DEG MIN SEC <br /> i I t r LOCATION ShLTCII ACTIVITI (zL) <br /> NORTH ._ NEW WELL <br /> z <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> Other(Specify) <br /> DESTROY{Describe <br /> Procedures and Materials <br /> Under GEOLOGic COG} <br /> PLANNLD USES () <br /> I I f1i WATER SUPPLY <br /> ' r Domestic . Public <br /> I I Irrigation Industrial <br /> y <br /> I I W MONITORING <br /> TEST WELL <br /> i CATHODIC PROTECTION_ <br /> HEAT EXCHANGE— <br /> DIRECT PUSH <br /> INJECTION <br /> I VAPOR EXTRACTION <br /> I i SPARGING— <br /> I SOUTH REMEDIATION <br /> 111irttintr orlhxribe I)Wattr of Wdffiinni R<adi Iiililrlrnl!s <br /> I I Ini(rs Hlun itt god(worh a nm %e arlrlilmltal II(r1a i if OTHER(SPECIFY) <br /> nrrewirry PILAIT RF ACCURATE&101117 IF <br /> I i <br /> WATER LEVEL & YIELD OF COIIPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> I I 2WATER LEVEL I (Ft)&DATE MEASURED ? <br /> I I ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAI DEPTH OF RORINC I e(,t) TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TO1AL DEPTH OF COMPLETED Lt Ir (hest) 'iLlay7101be iepiesentrati�e ofa uell's long-t(imryiekl <br /> DEPTH CASING (S) DEPTH ANNULAR NIATERIAL <br /> FROM SURFACE BORE HOLE TYPE() FROM SURFACE TYPE <br /> DIA r w a a MATERIAi! IN7EHiNAL GAUGE SLOT SIZE GE HEN <br /> (Inched z w z� GRADE FILTER PACK <br /> a DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft 10 Ft ce 0 oo (Inches) THICKNESS (Inches) Ft t0 Ft ✓ ✓ ✓ (TYPE/SIZE) <br /> h i T' % f l r f V" <br /> II I <br /> ATTACIINILNTS (.�L) CERTIFICATION STATENILNT <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geologic Log <br /> Well Construction Diagram NAME.' <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> — Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> _ Other <br /> I <br /> Signed <br /> ATTACH ApplT10NAC INFORMATION IF IT EXISTS Si A WELL DRILLER/AUTHDRIZED REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> Dllx lbS t;r� )1 e; IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />