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— � DWR U' ONLY — DO NOT FILL IN <br /> OR18INAI_ <br /> S"I-:1'I'S OF C:Il.3F01;\11 <br /> File with DWR 'ELL COMPLETION REPOT STATE WELL No.nsTATIDN No. <br /> ��/ Rcfcr rrr fnslrncN<ru Pnatpltic•f <br /> Page i of Kw <br /> 0,kv le1''S `e ell No• ' 820309 LATITUDE LONGITUDE <br /> Datc Work Began ( `� 9 Endedl_ � � { <br /> Local P(:rinit Allencv� v n N ` cc' APNrTRSIOTHER <br /> Permit No. Q } Permit Date <br /> GEOLOGIC LOG ttyy^�'� �uw 11'ELL OWNER t�^ `. J <br /> ORIENTATION {'�) !VERTICAL —HORIZONTAL —ANGLE ,.,_—(SPECIFY) Naini—•6��r� � �•�L <br /> � <br /> DRILLING y ` ii NN N* Mauling AC1C1rCSS R �nC�r - <br /> METNOD Ito lC910in Ak il1Jl0 .31'r?t� n .12 <br /> � C1� g ]�i � �i <br /> DEPTH FROM DESCR[PTION SDS <br /> SURFACE CITY 1— � STATE 21P <br /> Ft. to Ft. Drsrribc ntrrtr rtnl. grafi si.r, calor. rfc'. — �j%,L� 0CT'A i0N <br /> .Add (ISS s, e W a y <br /> rKGtf _ LL Lofr cit. <br /> County� S! 14 TO 'l I yl. <br /> -1PN Book PRL Ya-C'el_1 <br /> Toi RanL;e Section <br /> I LatitudeI I NORTH Longitude_ I I WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCI3 T[VITT (2�L) <br /> NORTH NEW WELL <br /> MODIFICATION'REPAIR <br /> — Deepen <br /> C [— kT r N (` tt L D — Other(SPec,ly) <br /> 1 1 r C V F L� <br /> , /1 �- p DESTROY(Describe <br /> '_1 1 Procedures and Material,, <br /> I Under"GEOLOGIC LOG") <br /> PLANNED USES I2) <br /> WATER SUPPLY <br /> — Domestic Public <br /> I Irrigation Industrial <br /> I < MONITORING <br /> Lu <br /> TEST WELL <br /> CATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH— <br /> INJECTION <br /> I t VAPOR EXTRACTION <br /> { SPARGING— <br /> SOUTH REMEDIATION— <br /> Ifln4rate or Dewribe Distance of Well1Frow Roads-,Bpi ldhwp <br /> Feriec.s,Ricers,etc.and attach n map L'.se additional paper f OTHER(SPECIFY) <br /> necessary-PLEASE BE ACCURATE&C031PLET.E. <br /> NATER LEVEL%{.& YIELD OF CO\iPLETED WELL <br /> 1 I DEPTH TO FIRST WATER%=(FI.) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC 9 p -3 q I l l 1 ,9 <br /> 9 <br /> WATER LEVEL t3 (Ft.)&DATE MEASURED J -- <br /> �(} ESTIMATED YIELD ' N A (GPM) &TEST TYPE /► <br /> TOTAL DEPTH OF BORING _� 0 (Feet) TEST LENGTH�(Hrs)TOTAL DRAWCOWN NA (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL _____CZ_Q_(.Fee0 'lYlay not be repi-ese'antati,'e of a hell's tang-term yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE( ) FROM SURFACE TYPE <br /> HOLE <br /> a INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> IDhAs Y ¢ 60 _ MATERIAL! FILTER PACK <br /> ( 1 a zj- a' GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft- to Ft. m v c» (Inches) THICKNESS (Inches) Ft. to Ft (TYPEISIZE) <br /> Q 10 pvc Z Sck 4 b n Z ✓ <br /> 30 5a JCS Z SII 0 U. ZQ 2 ✓ <br /> 28 so ►/ #3 5aKcL <br /> I <br /> I <br /> I <br /> ATTACK,NIENTS (z�!) CERTIFICATION STATEMENT <br /> / I,the undersigned, Certify that this report rs complete and accurate to the best of my knowledge and belief. <br /> • Geologic Log �V/{�``fU1 11 E <br /> Well Construction Diagram NAME • " •` r) F� 1 Di <br /> (PERSON, FIRM, OR CORPORATION) (TYPEC DR PRINTED) <br /> GeophysIca■l{Log(s) F{Q, r- A 94511 <br /> Other Soil/Water <br /> �J 1 t Chemical Anaes <br /> ADDRESS CITY STATE ZIP <br /> 41 <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL ILL IAUTH IZ D REPRESE 7A71YE DATE SIGNED C-5l LICENSE ND ER <br /> D11'!t IsS ttEV ll-s7 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />