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UHIII.MNAL 51A1t ur LA11runivlA - <br /> File with DWR WELL COMPLETION REPORT <br /> Page i of Q Refer to Inrtructrort Pamphlet STATE WELL NO,STATION NO <br /> Owner's Well No U r 1 No <br /> 11 <br /> J JbL J LATITUDE LONGITUDEDate Work Began D Ended 111410-0 <br /> Local Permit Agenc,* J <br /> N F i Permit No z Permtt Date 10 17 In APNITFiSeOTHER <br /> '� GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) yERTICAL _.,_14ORIZONTAL _ ANGLE —(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Aren <br /> L s 13 e <br /> DEPTH FROM f 0$ �' <br /> SURFACE DESCRIPTION <br /> Ft to Ft Dercnhe material Aram size color etc CITY STATE ZIP <br /> WELL L CATION <br /> dcl,5 Address t r ► i <br /> D Ctty S <br /> 13 w I441 Tt( Counth5AAA S6q <br /> 13 1 S� APN Book Page Parcel <br /> t6 2 3 Township Range Section <br /> 38 or <br /> 23 <br /> C Sl Latitude 8 ' k NORTH Longitude , 1 WEST <br /> p f? J� 1 !'t DEG MIN SEC DEG MIN SEC <br /> SIJ LOCATION SKETCH 9.CTIVITY (�} <br /> L13 q8 C NORTH _✓NEW WELL <br /> 418 !�3 ' G MODIFICATIONIREPAW <br /> jc� 8t —Despite <br /> Other(Specify) <br /> S 8 /� 11 <br /> 6 O 3 Sit DESTROY(DescnDe <br /> w <br /> ProceduresnMaterials48 -73 '0% 1 St GERLOGICG <br /> 73 L <br /> it-78 <br /> ti PLANNED USES) <br /> 83 w SI W W ✓(�) <br /> 2 p �+ 3: a MONITORING <br /> 6 3 SO St 7� w C - I`[ WATER SUPPLY <br /> 8 3 3 .51 ;,W 1 �J V_1,1111 _ Domestic <br /> 3 C - I — lac <br /> a ; 10-5 C, F'L[t�e r — Imgation <br /> 10 1#$ t industrial <br /> Iia 120 l _ TEST WELL <br /> CATHODIC PROTEC <br /> i SOUTH TION <br /> 111- <br /> trate or Describe Distance of Well from Landmarks OTHER(Spemty) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE lr COMPLETE <br /> MEILLING THOD �5"/ <br /> FLUID <br /> WATER LEVEL & YIELD OF COMPLETED ELL <br /> DEPTH OF STATICI? T7 2 1 ( 1 20Oa <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING !Z� (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not he representatize of a well s long-term yield <br /> CASINGS) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA a MATERIALI DIAMETER OR WALL IF ANY CE BENFILTER PACK <br /> (Inches) c c d GRADE MENT TONITE FILL <br /> Ft to Ft y c» (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> (�) (4) (L) <br /> O V1, C 2 0 O o <br /> lid 12a PVC S elo 0. Q 20 10q : 10 <br /> lab 12D t9 <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I the undersigned certify that this report Is complete and accurate to the beat of my knowledge and belief <br /> — Geologic Los <br /> — Wail Canstracs+on D9Wa3Tk NAME <br /> 2 (PERSON FIRM OR CORPORATION) (TYPED <br /> (TYPED OR PRINTED) I1� l/+.X11,,_.., � �Lr ��� <br /> Geophysical 1_09(s) 74,5� N^r°�i l.. M\e QA.CJ�O C6 W�J <br /> Sod/Water Chemical Analyses <br /> ADDRESS GIT // STATE ZIP <br /> Other �t r2� (� f 1 <br /> ATTACH ADDITIONAL 7NFORA(AT10N IF IT EXISTS Signed <br /> WELL ORR.LERlAU6-10 <br /> THORIZRESENTA E DATE SIGNED C57 LICENSE NUMBER <br /> OWR ISS REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />