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VClltalryHL b1Alh Uk' LAtAkOHNIA <br /> File with DWR WELL COMPLETION REPORT <br /> Page 1 OE � Refer zo Innruc[ion Pamphlet <br /> STATE WELL NO rsTAT(ON NO <br /> Owner's Well No 3 .A <br /> No 5 3 6 41 ❑ <br /> Date Work Began It 7 � Ended 1 I 13W LATITUDE LONGITUDE <br /> Local Permit AgencNm a +�6 i , <br /> • Permit No Zgy�Z- Permit Date t 1 Way <br /> GEOLOGIC LOG 1F WELL OWNER <br /> ORIENTATION (1) VERTICAL _,._. HORIZONTAL _ ANGLE — (SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address X -76 D2�CA+ <br /> A <br /> DEPTH <br /> FACEM DESCRIPTION (� <br /> STATE ZIP <br /> Ft to Ft Describe mazenal grarn sire color etc CITY WELL L 0 C TION <br /> t s( 4- Address 411 E <br /> I S ZS St 1+ w l CAN <br /> 2S 3 S SL Count-, Saea Jo aq uikn <br /> 3 P5 S W APN Book Page Parcel <br /> qSS ssa„n Township Range Section <br /> S Latitude 140ATM Longitude [ WEST ; <br /> 6 3 -7 5 '5 L 14- DEG MIN SEC DEG MIN SEC <br /> +7 _LOCATION SKETCH �CTIVITY <br /> 6 1 S `` NORTH NEW WELL <br /> L <br /> t MODIFICATIONIREPAIR <br /> 85 4 C C —Deapen <br /> s los c 5L14- <br /> Other(stiecdv) <br /> to S 12D S <br /> DESTROY(Desenbe <br /> Q Procedures end Ma[enals <br /> ' Under GEOLOGICLOG) <br /> t ti PLANNED USE(S)- <br /> U) <br /> MONITORING <br /> F <br /> WATER SUPPLY <br /> I Domesllc <br /> Pubtle <br /> i <br /> Industrial <br /> TEST WELL <br /> .,.. CATHODIC PROTEC <br /> SOUTH V TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE U COMPLETE <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD (GPM) E TEST TYPE <br /> TOTAL DEPTH OF BORING 12O (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL IW (Feet) 'Mav nor be representative of a well s long-[ern yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BOLE TYPE � FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA W o ii MATERIAL! FMIENT <br /> BEN <br /> llnches) c zoc' a GRADE DIAMETER OR WALL IF ANY TDNITE FILLFILTER PACK <br /> Ft to Ft m c» y (inches) THICKNESS (inches) Ft to Ft (� ) (� ) (TYPEISIZE) <br /> D I"_S 8 ✓ 1 Pvc, _31q <br /> 5 D o <br /> 11-7-9- i`10 8 AUC Z s 13 16- ✓ <br /> 6.S 12-0 D <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> GeadogicI the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> a Well Con L� y k r� 1 �. <br /> Well Constracbdi Oiaprati NAME V " '^� � �l%M <br /> (PERSON FIRM OR CORPORATION) (TY OR PRINTED) u'y/�—�7 <br /> Soil I W ter Lemic P o Soy— 1 Lfl c A 9 <br /> Sod!Water Chemical Analyses <br /> ADDRESSSTATE ZIP <br /> other CaITY 7 V2 Ov -72090 <br /> ATTACH AODMONAL INFORMATION IF IT Exlsrs Signed <br /> NTA <br /> WELL 6RlLLER/AUTHORIZED ESE TIV GATE SGNED C57 LICENSE NUMBER <br /> DWR 188 REV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />