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06ADRUPLICATE STATP Of CAI 1h01`iDWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I of l Rtftr to Lrstru+ttnn Prian)rlalr! STATE WELL NOISTATION NO <br /> Owner's Well No +' - No 703978 1 L❑ ❑ j <br /> Ditc Wolk Beg In Ended LATITUDE LONGITUDE <br /> Local Yenrut Agc,nc,y ' <br /> Pcrinit No 1 Ycrinit Date APNITRSrOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓ ) 4 VERTICAL -HORIZONTAL _ANGLE _(SPECIFY) N inx r <br /> DRILLING + MailAddress <br /> DEPTH FROM METHOD FLUID Mailing <br /> SURFACE DESCRIPTION - <br /> FI to F1 <br /> Dcitribi maid ial grell+a Slzc tole+ (,1L CITY STATE ZIP <br /> _ WELL LOCATION <br /> Address <br /> I i I r <br /> Cit) <br /> Countv <br /> APN Book Page Parcel <br /> To%vnshlp lunge Section <br /> L,1titudic I __ 1 NORTH Longitude WEST <br /> I , DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (:) <br /> NORTH — NEW WELL <br /> I I <br /> MODIFiCATIONIREPAIR <br /> Deepen <br /> - Other{Specify) <br /> I ) <br /> DESTROY{Describe <br /> I I Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> ` PLANNED USES (�) <br /> WATER SUPPLY <br /> Domestic Public <br /> Irrigation Industrial <br /> ULLI ~ <br /> w MONITORING .� <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> a I HEAT EXCHANGE , <br /> DIRECT PUSH <br /> INJECTION ...� <br /> VAPOR EXTRACTION <br /> ' Si <br /> I I SOUTH REMEDIATION <br /> 1lbaslrhlr or Dt scl'bc Dntaiirt (f 11',11{zona Rnrids lila fdilrgs <br /> I I Icnccs Rn(?-s cic and attach a ina1) Lsi tirldatuandl 7a1)[a if OTHER(SPECIFY) <br /> necessary PLI ASF BL ACC URATF &C0WP1,1,T1 <br /> I � <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WFI L <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL D1 PTH OF BORINC r (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOIA1 DL1711 OF COMPLN7P D 1VELL (Feat) *May not he repterentatii of a u>cll't long-terra yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(''—') FROM SURFACE <br /> TYPE <br /> DIAr w o 5t MATERIAL_! INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft (Inches) S Q� GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> a J ) (Inches) t to FF MENT TONITE FILL (TYPEISlZE) <br /> co v LL (inches) THICKNESS F ( � ) (� ) (� ) <br /> I <br /> 7 - I <br /> I <br /> I <br /> ATTACHMENTS (.�L) CERTIFICATION STATENIENIT <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 11 i + <br /> (PERSON FIRM DR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> Sol)/Water Chemical Analyses <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION 1F 1T EXISTS Signed f 1 1, i + <br /> WELL DRILERlAUTHORIZED REPRESENTATIVE DATE SIGNED T-57 LICENSE NUMBER <br /> out; 1hs 11F1 1t 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />