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UMILZINAL blAlk ur c_At.irUTANIA - r <br /> File with DWR WELL COMPLETION REPORT <br /> Page I of <br /> I Refer to lnttruetion Parnpbler STATE WELL No/STATION NO <br /> Owner s Well No s 14,ANo 533643 <br /> 0 ❑ <br /> Date Work Began (1 7 Ended 4_71n LATITUDE LONGITUDE <br /> Local Permit Agency rt �^ v <br /> IER <br /> 0FDEPo. <br /> Permit No 8 Permit Date fI S db ' <br /> GEOLOGIC LOC WELL OWN H <br /> TATION (! VERTICAL - HORIZONTAL _ ANGLE -(SPECIFY) Name 4d4 M On <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Ming Address D 7 <br /> 6 C� <br /> FROM <br /> RFACE DESCRIPTION <br /> o F1 Describe rnaterral Kram size color erc CITY STATE ZIP <br /> Ft t <br /> i 1 WELL LOC TION <br /> Address 37 E MrsQr <br /> 1 r 2S 5( CitN <br /> S 3 St Count% <br /> 3 APN Book Page Parcel <br /> or <br /> Township Range Section <br /> / k or <br /> S , Set 1 �t arty` S LatitudeDEG ' MIN ' SEC Ott( Longitude DEG I MIN { SEC WEST <br /> 65, LOCATION SKETCH CTIVITY <br /> + (!) <br /> f I W NORTH _ NEW WELL <br /> I17 ' IZV t MODIFICATION I REPAIR <br /> r <br /> i <br /> aspen <br /> Other(Specify) <br /> DESTROY toescribe <br /> Procedures and Melanala I <br /> Under GEOLOGICLOG A <br /> r PLANNED USES)Lu <br /> -i <br /> as ✓ <br /> W MONITORING <br /> rSP-41A♦ d WATER SUPPLY <br /> V — <br /> Domestic <br /> Public <br /> Irrigation <br /> Industrial <br /> TEST WELL <br /> ..._ CATHODIC PROTEC <br /> + OUTH ✓'TION <br /> Illustrate or Describe DuWnce of Well from Landnwn& OTHER(Specify) <br /> such as Roads Buildings Fences Rivera etc <br /> PLEASE BE ACCURATE & COMPLETEDRILLING <br /> METHOD sA FLUID <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) 6 DATE MEASURED <br /> ESTIMATED YIELD' (GPM) d TEST TYPE <br /> TOTAL DEPTH OF BORING 20 (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) f <br /> TOTAL DEPTH OF COMPLETED WELL (Feet► "May not be representative of a well's lone(-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE TYPE INTERNAL GAUGE SLOT SIZE <br /> DIA ,C W W MATERIAL/ DIAMETER OR WALL IF ANY CE $ FILTER PACK 1 <br /> pncnes) c =� l GRADE MENT T816A FILL <br /> Ft to Ft v u (Inches) THICKNESS (Incites) Ft to Ft (TYPE/SIZE) <br /> S ✓ 1 PVC 3l 0 o 1 d. ✓ <br /> I S: I 1 1 8 V Wa 2 Ito. t > <br /> q5 ; 1W $60 <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> I,ieelpgtc Log '{ �1 y <br /> Wag Canainictton Diagram NAME �S Calc e_ �/{y 1 1j <br /> (PERSON FIRM OR CORPORATION) (TYPED HINTED) <br /> Geophysical Loq(o) 2 t <br /> Soill Water Chemical Analyses 6 3` 0�L C t�� San Q <br /> ADDRESS CITY k ,�/► STATE ZIP �( <br /> Other 12 (/'' 717 S 0 <br /> ATTACH AD0n7ONAL INFORMATION IF IT EXISTS Signed <br /> WELL DRILLER/AUTtiORIZ RESENTATIY DATE SIGNED C 57 LICENSE NUMBER <br /> DWRiMREV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />