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ft sf�l, <br /> ik ' Y•''�bIIQUADRUPLICATE STATL O}' CAI iPOfi\IA DWR USE ONLY — DO NOT FILL IN ` <br /> p1r� For Local Requirements WELL COMPLETION' REPORT <br /> r Page of l r Rrfir to Instrwoon Painvidet STATE WELL NO ISTATION NO <br /> 1 Well No 4 1 +� t ____ No <br /> jOwnell <br /> � _ _ �. ?03818 LATITURE LONGITUDED lite 'Work Bcg°m `] G -fi:t] Ended 12 -�°I 4 t <br /> Local Penult Age,nu' � <br /> APNITRSIOTHER g <br /> Pernut No o� Yw Permit Date <br /> ' <br /> h GEOLOGIC LOC «'ELL OWNER all <br /> ORIENTATION (�) �VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Ndtlle� +"'�'�?�'��`� r �'{��sr<` tI P�A'}l�JIM 7'.I �! <br /> F DRILLING <br /> DEPTH FROM METHOD ;53:� KLUID • 1111th. Addr('S;s <br /> SURFACE USCRIPTION `�t °ATE <br />}1 Ft to Ft v Dcso ib( 71 atcri Cil grain si=r tolor (IL�. r� < 'S t <br /> BVI'LL LOCATION <br />` i i l�`�✓n yi ✓"^ ,Addiess <br /> ,._,. <br /> cil �-' <br /> Ito' - }APN Bookr Pabe� '? Pa]ccl <br /> ' <br /> Toarnshlp` Hangs Section '4 <br /> I I NORTH I.n11g1t11dG WEST <br /> r ✓ �' -'j)'� DEG MIN SEC DEG MINSEC ' <br /> LOCATION SKLTCH ACTIVITI <br /> NORTH 1)"If NEW WELL <br /> MODIFICAT30NlREPAIR + <br /> 4 — Deepen <br /> — Other(Specify) + <br /> DESTROY(Oescr+6e <br /> Procedures and Materials r+t <br /> Under GEOLOGIC LOG) <br /> CIO ( t <br /> PLANNED USES r <br /> t ti fl�P' { I WATER SUPPLY <br /> ' � � t Domestic — Public, ` �I <br /> v i Irrigaten .. Industrial <br /> tL t 4 MONITORING <br /> I4 ' 3 4 •t�f w P 'r TEST WELL— '1 <br /> f <br /> },,„�!y CATHODIC PROTECTION— `s <br /> t ; I HEAT EXCHANGE <br /> j '...�.......��'» M 4 DIRECT PUSH <br /> Vv INJECTION <br /> 1 R <br /> a r VAPOR EXTRACTION <br /> SPARGING <br /> y SOUTH REMEDIATION— <br /> llGrtit(dtr or Dtruibr Utsta+u( rf 1Prlf front Runtls Iitnlrluigs 1� <br /> H(ure s Rat n Plc and attach a inrrr) Vsc addOlowd rrlalier if OTHER(SPECIFY)— <br /> u<nNary PLLASF BF ACCURATL#;(Ob1P1 FTt ° r <br /> + ' 1VATER LEVEL & 1ILLD OF CONIPLETED NIFLL <br /> s <br /> ti I I DEPTH TO FIRST WATER r fQ (Ft) BELOW SURFACE { i{ <br /> � PSYr f3 "1 <br /> DEPTH OF STATIC j jor <br /> *4 Ihyyaq � <br /> ' WATER LEVEL QT(Ft)&DATE MEASURED <br /> v t[ P I . F i �yx'd tl"yrr sE�l <br /> i ESTIMATED YIELD Y (GPM) & TEST TYPE <br /> I TOTAL IA }'l H Of BURIN[' -? (Feet} TEST LENGTH (Hrs) TOTAL DRAWDOWN Y` r A (Ft) <br /> COTAL DLFTH OP CONIPLE1ED 11'171 I �(Fect) 'May not be lepi esentnnze°t rt well's long rc(��a yield <br /> f <br /> I iDEPTH CASING (5) DEPTH { ANNULAR iIATERIAL <br /> FROHOLE <br /> M SURFACE BORE TYPE('' ) FROM SURFACE TYPE u I <br /> ( { <br /> DIA m w ¢o w MATERIAL 1 INTERNAL GAUGE , SLOT SIZE CE BEN FILTER PACK" <br /> (Inches} Z w Z r a GRADE DIAMETER OR WALL IF ANY ° ° MENT TONITE FILL, A,f <br /> Ft to Ft m cwt �� (Inches) THICKNESS (Inches) Ft to FI { �) (� ) (�) {TYPEISIZE) s <br /> N LL y <br /> , k <br /> "d <br /> t A �4 <br /> � }#r .f i r 1•lf` � W'r} 1,,,,.,(.�t�; 77 f,� ' .i �. � r t <br /> I Y � <br /> ' ATTkCMUENTS (J) CERTIFICATION STATEMENT s <br /> - I,the undersigned, certify that this report Is complete and accurate to the best of my'knowledge and belief r. °}s <br /> Geologic Log �I <br /> r <br /> _ <br /> Well Construction Diagram NAME s� r r: f ' /� o y -' g <br /> P <br /> it <br /> (PERSON"FIRM OR CORP6RATIONf (TYPED PRINTED) r'J� <br /> { Geophysical Log(s) I <br /> f u SoilNVater Chemical Analyses ADDRESS <br /> �✓ ' R �' j,GTS CITY STATE TE 2IF <br /> ` ' ZIP <br /> Other <br /> ' <br /> ATTACH ADDITIONAL fNFOAMATlON 117 1T EXISTS Signed.'".y �'�"~ ✓ �"� �-- -- J M ,��r- �', ' 5% k l <br /> t g :WF—IrIl ILCER7AUTF1t7Rl1Ep REPRESENTATIVE DATE SIGNED C 57 LIU E HUMBER t, <br /> nit 11-1SS R1 t 11 s; IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM r' z <br /> r ( <br />