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' THIPLICATE til'%TE OF l:AJJi`(IH\I{ AWP. L'SE O1`1LY� PQ NOT FILL rN <br /> Q:vner's Copy WELL COMPLETION REPORT 1 . I I <br /> Pagr—(I� rrr l e(vJrrwd....eeht;1,flhl(•Y STATE WELL N0;S7ATION NO <br /> Owner's Well No, No. �7 4$ �L_�L�__!_�❑I I��f�� <br /> Datr` �'<.mli l3vo Il. go LATITUDE LONG,TUDE <br /> i (',l7llf'(l <br /> €fwal Pt r11+1t Ar�cnc� �- i i L_I I I 1 j1 I I <br /> Health Dept. APNiTRSJOTHER <br /> F(unit �cl. U� &`Permits Date <br /> ( -} )G11 L(}(: WELL OWNER <br /> ORIENTATION (v I �_VEA TICAL HORILONTAL —ANGLE _(S-ECIFY) NivilE,. S'i � —r,r%_ack <br /> METHOD <br /> �� Mailing Address _�?LSA 1!- 1 ine — <br /> ' oEPTw __F1 <br /> METHQp FLi1SD�_ t, ' <br /> suRFAr,E <br /> DESCRIPTION' <br /> Tracy 1% e <br /> F:. to F1 DescriLr J3 atcrial, xize-. r"lor, off. CITY ST0.TE ZIP <br /> WELL LOCATION <br /> Cal I Adilrr•sN - r n-i a Rd . <br /> — Sell 7 - <br /> (ah' Traey <br /> 36 37r AV Il1tV FS7am—Ii.-- - <br /> AI'I�I R(I<)k Page Parcel <br /> Ttr�cnshil7 Aangt•— S(ctinn <br /> 179 clayL1ltltlld( i i NORTH €.(nl itiult --�—.L _ wEST <br /> DEG. r.Ilrr, 5EC, DEr ),(Ira S=C <br /> UID Sand <br /> LOCATION SKETCH ACTIVITY (,L} -- <br /> ' <br /> Blue C 1 4 vii NORTH- -X. NFW WELL <br /> ' ;-357_- MODIFICATION'REPAIR <br /> WELL ABANDONMENT — Deepnn <br /> i4iiiiats�iii■ilE — Olher(Sp9CIlY) <br /> 4 C Lay �r 0-3 Sent lnite - - D6cedwa{Dd Mate <br /> � I Pr�CedcnBs and AAarBnif$ <br /> 3-501 Fill-up Lrnde "GEOLOGIC LOG', <br /> 501 Approximate Depth PLANNED USES (zL. <br /> ---- j <br /> WATER SUPPLY <br /> -'-'--•-�r-----T µ <br /> 60 <br /> STEEL <br /> TEE . DIAMETER X_ Domestic Puohc <br /> a:.,ne+ln^. In oas,.•rnr <br /> N <br /> w w MPNITORIN!i____ <br /> TEST WELL T. <br /> r CATHODIC EXCHANGE G <br /> E ° }TEATT EXCi(ANGF— <br /> DIRECT PUSH — <br /> INJECTION— <br /> VAPOR EXTRACTION= <br /> r ' SPAAGING <br /> r --SOUTH REMEDIATION <br /> T-' II7+r fl'+d•or 7!rrrribi l:ictnatr ilf Tl'rf1 frrriil R� ?&.BrrririenLv. <br /> RI('r J, rfr' ewd atIfIvi,ri me1r.C`sr nrlrr'itirnrq!11rrgrrr r{ OTHER(SPECIFY)— <br /> ury+•�xrtl-rI. PLEASE BE:AUGUR4TE L-C.(1D1Pf.ETV. <br /> ' WATER LEVEL & YIELD OF COMPLETED W 'I',, <br /> .� DEPTH TO 'FIRST WATER iAe I (FL} BELOW SURFACE <br /> r I DEPTH OF STATIC ••r <br /> ' WATER LEVEL <br /> I (Ft,(&DATE MEASURED �I <br /> ESTIMATED YIELD ' - jGPMj & TEST TYPF _ <br /> TOTAL i?lilTil !)1' 11C)RI\(. 0 -- FrrtJ TEST LENGTH _ (Hrs.) TOTAL DRAWOOW.4 <br /> (Ft.) <br /> TUTM, DEPTH OF' (;()NIPLE:TED M'E.LL {Pelt <br /> :'I lrf 1'11!31 IT 1111f1TC.TE'JJllJrii'('OJ'a ii'Pj�'.Y IOJJ�r-fYr7J1 1'lQ�d. <br /> ' DEPTH BORE- CASING (S) DEPTH ANNE,ILAR MATERIAL <br /> M <br /> FROSURFACE HOLE TYPEFROM SURFACE <br /> TYPE _ <br /> E}IA. w a MATERIAL' INTEF(NAL GAUGE SLOT SIZE CE- ;BEN- <br /> rON,' - ilncnesl - ~ a GRADE DIAMETER OR WALL 1F ANY FILTER PACK <br /> RI, ro Ft a MENT TE FILL <br /> Oncnesl THICKNESS I Uncnesl Ft to Ft. {TIPg'S1ZEI <br /> (_ r <br /> WO 140i <br /> �- M <br /> I <br /> I{-•-- I <br /> ' <br /> ATTACHMENTS <br /> CERTIFICATION STATEMENT <br /> — <br /> Geologic Log <br /> I,the undersigned,cetlify that this report is complete and accurate to the best of my knowledge and belief, <br /> — Well Construction D,agrarrl NAME <br /> Geoprtysical LN(s) (PERSON_ FIRM, F. CORPpRATIDN} (TYPED OR PRINTED) - <br /> - woil'Waler Chemical Analyses2525% PEI ANLIALF AVL �_n r 5j_Rise <br /> .�. Other ADORES] CITY STATE IIP <br /> ' ATTACH ADDITIONAL JNF0RAlAT10N, he IT EXISTS, Signed <br /> WE(.ORRLERIAi1TN4R11E PR if !y DATE SIGN C-57 L}t,NS L'M$ER <br /> I1'+t'It IYti It F;1 !I.ci IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM, <br />