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ORIGINAL Srm ()I ( %ii)(ntNtk OWa P_ 16- <br /> ONLY — DQ Nor FI t IN <br /> File with DW WELL COMPLETION REPORT 12 � <br /> A <br /> i'a)ge 3• of R,ler to Instru.taan lartnphtar STATE WELL N I STAIMCN NO <br /> (Tt%,nt,r S Well No f'" 1/"P „3 No O <br /> D Itt Work lit gin J 4J J Kj S -2— E.Tided 7 LATITUDE LONGITUDE <br /> E_Ocsl PLrnlit Agency So�� .��,,-,, Ga��, r E.����d .ted...-, .. .._s+� *�► I <br /> Permit NnZ-"� f?=141YZ APNrTR roR <br /> �Z 3 S _ Permit Date <br /> GEOLOGIC IOG I WELL OIVNER <br /> ORIENTATION {!) VERTICAL _ HORIZONTAL — ANGLE _ (SPECIFY) Vamt CP-k5-0C&-f c_ri:&-�'r1 Ct- E3LIPt r <br /> DEPTH FROM DEPTH rO B IRST W WER (Ft) BFLOW SURFACF Mailing /0/—? 7D <br /> SURFACE DESCRIPTION <br /> Ft to Ft Describe material grata nu color etc CITY STATE ZIP <br /> WELL LOC#TION <br /> Address li L✓CS s^ „ Fre Aft co 10 _.,.._ <br /> city_ - - STdc.K <br /> County _SAN oda.c.— [r/"r <br /> APN Booker-1 --3*�/nPagl���� Parcel <br /> T,nship IN Flange ection 4 _ <br /> IF <br /> Latitude I. NORTH Longitude I T WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH A IVITY (�) <br /> NORTH SEW WELL <br /> a <br /> MODIFICATION!REPAIR <br /> Y Deepen <br /> omen(spetilY) <br /> 'xi tA <br /> r <br /> —DESTROY(Descrrbe <br /> ` ,Ly Procedures and C40C,la <br /> ` {J fJnder GSR40C+1GCt7G ) <br /> PLkNNE USE(S) <br /> w a ) <br /> Lu MONITORING <br /> i o <br /> Y <br /> WATER SUPPLY <br /> i <br /> f �� <br /> Domestic <br /> Public <br /> ' t <br /> Irrigavon <br /> Industrial <br /> TEST WELL <br /> f <br /> — CATHODIC PROTEC <br /> ` SOUTH TION <br /> Illustrate or Descnbe Distance of Well from Landmarks — OTHER(Specity) <br /> such as Roads Sudd:ngs Fences Ravers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> ' METHOD Ur+ FLUID �! <br /> WATER L °VEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATICr <br /> WATER LEVEL S ,� (Ft) & DATE MEASURED /2- J/:v_5�QESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft 3 <br /> TOTAL DEPTH OF COMPLETED WELL__ Y0 _ (Feet) •May not be representative of a well.r Zong-term)aeld <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE <br /> HOLE J INTERNAL GAUGE SLOT SIZE <br /> DIA <br /> z =r MATERIAL! DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> 4 s o GRADE MENT TONITE FILL <br /> Ft to Ft m y � _ (Inches) THICKNESS (inches) Ft to Ft (TYPE151ZE) <br /> Zu D 10 1 tr e)2- !6 <br /> 1 O <br /> I <br /> I I <br /> xTTICHSIE',TS (!J CERTIFIC IkTION ST,TENIENT <br /> Geologic Log I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME 2 C I"� 1 „'r e���-i �r Vllci F{(aC e_— <br /> Geophysics[Log(3) �u YL L ✓ fOCt4_T 1 <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> p (J �;) <br /> SadlWater Chemical Anaiyaes 70-5-cr`Gl�c.i �' IVB" W. -Scc SO <br /> Other ADDRESS w CITY �.y STATE Lt/��X <br /> ATTACH ADDITIONAL swop rioiv IF!T EXISTS Signed <br /> WELL DRILLEWMTHORIZED REPRESENFATI4E DATE SIGNED C 1 LICENSE NUMBER <br /> uu It 1411 It EN -`KI IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />