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L <br /> �R1GIith STATE OF CALIFORNIA _ <br /> If <br /> File with DWFi WELL COMPLETION REPORT N r <br /> ! Page OF _� Refer ra Instrac[itrn Pamphlet SFA WELL NO.r TATION NO, <br /> JLOwner's Well No. No. /� r� 2 (� O 7 ❑ ❑ <br /> Date Work-Began L Ended �2 '} G J Q ! LATITUDE LONGITUDELocal Permit Agency �' M/s/ <br /> Permit No. Permit Date O <br /> GEOLOGIC LOG WELL OWNERJ <br /> ORIENTATION (!L — VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name Rox-r <br /> DEPT}i FROM DEPTH TO FIRST WATER (FI.) BELOW SURFACENtailing Address <br /> SURFACE DESCRIPTION C-7z� <br /> Ft. to Ft. Describe rnaterial,grain fine,color,etc. CITY STATE ZIP <br /> WELL LOCATION <br /> Address �` 1 �I! fi`/•�/ ry�: <br /> City �d ZF1 <br /> County G'[jv1n <br /> APIV Book page "2 <br /> or Parcel �� <br /> —� <br /> Township - Range Section <br /> or <br /> i Latitude INORTH Longitude ' WEST <br /> DEG. MIN. SEC. DEG, IN. SEC. <br /> LOCATION SKETCH yGTIViTT {�) <br /> NORTH ,[NEW WELL <br /> MODIFICAT10WREPAiR <br /> I <br /> i <br /> Deepen <br /> I <br /> —Other(Specify) <br /> DESTROY(Desaibe i <br /> Procedures andMaterials ' <br /> - ' Under" OLOGICLOG') k <br /> >- <br /> P L A Vt D) EUSS) f <br /> w a (! <br /> Su MONITORING <br /> i <br /> WATER SUPPLY <br /> ' � I Comeslit: 5 <br /> �ry I Pu61ic <br /> $ I IrAgaiion <br /> �,.., Industriat <br /> ' '_TEST WELL" t <br /> CATHODIC PROTEC- <br /> SOUTH T10N <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Spec'ry) <br /> such as Roads.Buildings,Fences,Ricers,etc. <br /> PLEASE BE ACCURATE b COMPLETE. <br /> I I <br /> DRILLING - <br /> I <br /> METHOD ' <br /> d)Cr�FLUID_�{•�ON�I! <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC/ <br /> WATER LEVEL ! (Ft.) & DATE MEASURED j <br /> R ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BOR}NC (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) j <br /> TOTAL DEPTH OF COMPLETED WELL .. (Feet) 'rtlay not be representative of a well's long-term yield. it <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL i <br /> FROM SURFACE BORE-HOLE TYPE L! FROM SURFACE TYPE <br /> � <br /> DEA, c W MATERIAINTERNAL GAUGE SLOT SIZE CE- BEN- <br /> o DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) a o GRADE MENT TUNITF FILL <br /> Ft- to Fl. �, c» � (Inches) THICKNESS (Inches) Ft. to FL (TYPEtSi2E) <br /> a. C <br /> a Q <br /> .o <br /> ATTACHMENTS (.!L) CERTIFICATION STATEMENT 1 <br /> 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> �aologic Lag �p,r may► <br /> �. WSU Construction DiagraNAME <br /> m <br /> i (PEFSUN, HRM, OR CORPORATION) (TYPED OR PR ED) <br /> — Geophysical LDg(s) /� L y�/L <br /> _/6– <br /> pOdjWsIar G smicsf Anayses W �V ZIP SCC <br /> ✓ DRESS CITY 5 TE ZIP <br /> Other SIX <br /> 0 <br /> ATTACH ADDITIONAL INFORMATION. F fT EXISTS. Signed <br /> WE LLE AUTfi RIZEO RE H lVE - 1) 6 C57 LICENSE HUMBER <br /> DWR 148 REV,7-90 IF ADDITIONAL SPACE I D, USE NE T ONSECUTIVELY NUMBERED FORM je <br /> c vva,7?Y <br />