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bFlIGINAL STATE OF CALIFORNIA M01 <br /> iwith DWR WELL COMPLETION REPORTPage—/Lof—/— Refer to lrtlrructton PampblerSTA WELtOH <br /> ' Owner's Well No No1 :11 E <br /> iDate Work Began Ended . 2 2 9 LATITUDE ❑ LONGITUDE <br /> Local Permit Agency ` a <br /> Permit No Permit Date _ <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (z::) X VERTICAL —HORIZONTAL —ANGLE ..,__(SPECIFY) Name <br /> ' DEPTH FROM DEPTH TO FIRST WAJER...,12—M) BELOW SURFICE Mailing Address t t SURFACE DESCRIPTION <br /> Ft to Ft Darnhe materral,grain sire color,etc CITY STATE ZIP 1114/d X,AL <br /> WELL LOCATION <br /> 1'rh <br /> �zeAddress La r <br /> ' -7� <br /> aj-IV City <br /> ZA <br /> County / ,J <br /> �� ' ftA"bw A P N Boo Page Parcel r <br /> fit/ Township Range oeZESectio, <br /> 1 p , or <br /> 1 r atitude--_ I 1 NORTH Longitude I„ WES <br /> �' ` DEG MIN SEC DEG MIN SEC <br /> ' C�mrjoLOCATION SKETCH ACTIVITY <br /> ' " J NORTH ��// <br /> _x NEW WELL <br /> MODIFICATION/REPAIR <br /> �. <br /> s i ro <br /> _ 46 —Deepen <br /> iJ <br /> is , „ eI)II.-f <br /> _—Other(Speeity) <br /> DESTROY(Dearribe <br /> Procedures and Marlenal� Under GEOLOGICLOG <br />' M �� PLANNED USES))17- <br /> W <br /> 1 ; LU MONITORING <br /> ' Ie ` "! WATER SUPPLY <br /> 67 h �' O 7rC V — Domestic <br /> + / <br /> e , y — Public <br /> - IRI9etlerl <br /> — Induetnal <br /> TEST WELL <br /> ' SOUTH CATHODIC PROTEC <br /> TION <br /> 111u3trate or Describe Distance of Well from Landmarks OTHER(Speclty) <br /> such as Roads Buildings Fences Rtners etc <br />' PLEASE BE ACCURATE & COMPLETE <br /> 1 <br /> ` DRILLING <br /> f t1✓ sLI�7 <br /> METHOD - FLUID_ C — <br /> WAT R LEVEL & YIELD OF COMPLETED WELL <br />' DEPTH OF STATIC --7' <br /> WATER LEVEL____ , (Ft) & DATE MEASURED S <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING._n. (Feet) TEST LENGTH (Hes) TOTAL DRAWDOWN (Ft) <br />' TOTAL DEPTH OF COMPLETED WELL�_(Feet) a May not be represemattve of a well's long-term yield <br /> DEPTH CASING(S) --DEPTH-- ANNULAR_MATERIAL <br /> � ._ <br /> —— --FROM-SURFACE l BORE HOLE TYPE = FROM SURFACE T TYPE <br />' INTERNAL GAUGE SLOT SIZE CE BEN <br /> (inches) r W rod MATERIAL/ DIAMETER OR WALL IF ANY <br /> Ft to Ft �, GRADE MENT TONITE FILL FILTER PACK <br /> m a LL (Inches) THICKNESS (Inches) Ft to Ft (TYPEiSIZE) <br /> 0 A S >'n <br />' fMen at <br /> J <br /> 1 t— <br /> IL <br /> 1 <br /> 1 <br />' 'ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Loy 1 the undersigned, certify that tilos report is compete and accurate to the best of my knowledge and belief <br /> Wall Construction Diagram NAME Gregg Drilling & Testing, Inc. <br /> Geophysical Log(s) - <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> --� <br /> SOO/Water Chemical Analyses Wo-ad MartYnez CA 94553 <br /> ADDRESS L CRY STATE LP <br /> ,.� Other <br /> ATTACH A1701rtONAL 1NFORAlAT10lk tF rr EXISTS Signed U q`�}- 8 516 5 <br /> WELL ESENTATIVE E SIGNED C 57 LICENSE Numa-FR <br /> DWR 198 REV 7 W IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />