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TRIPLICATE SPATE OF C4.LIFOR%IA <br /> Owner's Coy WELL COMPLETION REPORT <br /> Page k o{ _ Refer ro faitrsctroa P47n9hlct STATE WELL NO(STATION NO <br /> Owner s Well No `•1_ XILI <br /> No 554301 <br /> Date Work Began �� Enda M f LATITUDE LONGITUDE <br /> .-� <br /> Local Permit Agency'-AA.) �C''° 0 �c(AL f �Ptd� LI"'tr.r-+_ I I <br /> APNfTPSfOTHER _j <br /> 2 <br /> f Permit No5 L Permit Date f� 11 l`f - <br /> GEOLOGIC LOG \WE OWNER <br /> ` <br /> ORIENTATION (4) _YVERTICAL HORIZONTAL ^ANGLE (SPECIFY) Name"' A• 4f 5 <br /> 1t jt^ �~ <br /> DEPTH TO FIRST WATER+I (FL) BELOW SURFACE Nlailing Address <br /> DEPTH <br /> M FACEDESCRIPTION �"'� S 171,14 U*1 1 4� , ✓ l G P - <br /> Ft to Ft Desmbe material grain sire calor etc ^ " CITYr/ 4' \ : STATE ZIP <br /> WE L LOCATION <br /> 4 l.�at --L-- rq jt9_1A,1 WU ` - <br /> 6 ' 1 <br /> 1.41 vJ 'if 1` A, f41�+ I n t Irn G� City.. - <br /> t^ County <br /> r} <br /> Q �:��`• a _ +(1l r ° aPN Book ,• 'Page- Parcel <br /> nsI <br /> Towhip Range �_—Section - <br /> s J 1 <br /> L• '1 "� �' \ N ' ; r 1 L"atitMtide i i NORTH Longitude_ I' I WEST DEG MIN SEC DEG MIN SEC <br /> y � LOCATION SKETCH A.�TIVITY (�} <br /> " t Y My+ �' NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deegan <br /> �+ An L'L ( Other(Spacrty) <br /> .- .. - DESTROY A[ t _ tDescrlGa <br /> k e _ �y I}OQ Vwisr"reread ICL.Oala <br /> Pr- <br /> i Uadr^GEOLOGICLDQ) <br /> yr �. e- A M.)r)� -,J>� PLANNED USES) <br /> r r ` <br /> (�1 _� �+ t <br />' I f —I 11 <br /> r` Z -, WATER SUPPLY <br /> + r <br /> -4 q <br /> R Domestic <br /> 1 Public <br /> I r = <br /> I (� J trrigetion <br /> Industrial <br /> ' 'TEST WELL <br /> _ CATHODIC PROTEC <br /> SOUTH i+ TION <br /> Illustrate or Describe Distance of Well from Larldmarla _ .OTHER(Specity) <br /> such as Roads Buildings Fences Rrpers etc r <br /> PLEASE BE ACCURATE Fern <br /> r r <br /> 1 , , DRILLING <br /> METHOD- "lk am} �E A. - �i./��� FLUIL? <br /> WATER LEVEL & YIELD OF COMPLETED W LL <br /> I r DEPTH OF STATIG O <br /> WATER LEVEL (Ft) b DATE MEASURED 1 <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) _ TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft} <br /> TOTAL DEPTH OF COMPLETED WELL r L (Feet) May not be representarrve of a well's long-term yield <br />' DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA ,C W i MATERIAL/ CE- BEN <br /> (Inches) Z_ GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft y v e (Inches) THICKNESS (Inches) Ft to Ft (TYPE(SIZE) <br /> + t <br /> + <br /> ATTACH NIENTS (!) CERTIFICATION STATEMENT <br /> Geologic Log I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geophyartal Log(s) �.�I �JFEu� C <br /> 112 , N <br /> _� Well Gpnatruchpn Diagram NAME - •-— <br /> - (PRSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> r / r L1C1 7[ <br /> SorVWaterCham+calAnalyses M W l�f <br /> ADORES$ CITY r+ STATE IIP <br /> �.. Other S— <br /> ATTACH ADDITIONAL INFORAfATION IF 7T EXISTS S"..,l <br /> WELL DITILI.EIMMOIREPRESENTAFIVE DATE SIGNED C57 LICENSE NUMBER <br /> D"RIRS RE% -90 IF ADDITIONAL SPACE I$ NEEDE SE NEXT CONSECUTIVELY NUMBERED FORM <br />