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ORIGINAL STATE OF CALIFORNIA W R Y - FILL <br /> File with DWR WELL COMPLETION REPORT STATE WELL NO lSTAnON NO <br /> Page 1 Of 1 Refer to Instruction Pamphlet <br /> Owners Well No S r No 5 v 3 6 4 4 <br /> Date Work Began f ro Ended !l 8 drD LATITUDE LONGITUDE <br /> Local Permit Agency a+^ w v (C <br /> . Permit No -2-1-3B` Permit Date t( 3 p� P ' <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) t/VERTICAL _ HORIZONTAL _ ANGLE -(SPECIFY) Name �R I ■la�i <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address o -7blV <br /> Gs SURFTH ACE DESCRIPTION L 00 <br /> 57 <br /> Ft to Ft Describe material grain stze color etc CITY WLL LOC TION STATE ZIP <br /> >r- Address It/{ <br /> S P—LIA CItN S <br /> County 512aft J <br /> APN Book Page Parcel <br /> or <br /> Iowans ip Range Section <br /> Latitude ' _ NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEG <br /> LOCATION SKETCHeCTIVITY (:) <br /> NORTH NEW WELL <br /> MODIFICATIOml REPAIR <br /> Dsaprn <br /> `n _Olher(Specdy) <br /> vj <br /> DESTROY(Describe <br /> Q Procedures•ndMatenara l <br /> Under GEoLOGiCLOG 71 <br /> N PLANNED USE(S)- <br /> dc <br /> SE(S)- <br /> a ( <br /> � w MONITORING <br /> r WATER SUPPLY <br /> s��Wg <br /> Dam.aic <br /> Public <br /> 1' w it AG+'i Vtv Irrigation <br /> i <br /> Industrial <br /> ' TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH f TION I <br /> ' Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Busldings Fences Rivers etc i <br /> PLEASE BE ACCURATE & COMPLETE I <br /> DRILLING 1({' AMETHOD • 's FLUID <br /> NATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft} <br /> TOTAL DEPTH OF COMPLETED WELL `72 (Feet) 'Mav not fie representative of a well s long-term weld I <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE - <br /> d MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> PIA W rr �. CE SEN <br /> (inches) ` �+ c� s GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m H uq (Inches) THICKNESS (inches) Ft to Ft (� ) (� ) (� ) (TYPElSIZE) <br /> o 9- uC 3 Lit) D ✓ <br /> VC_ 2 t6,q 69Vol <br /> 872— <br /> O Ste. <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> Geolo"Log I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Wail Construction Diagram NAME r S Cr+ _ (,x 1 - <br /> �2(PERSON FIRM OR CORPORATION) (TYPED 1`OR� INTED�i)l1 4 [ � /^A ����� <br /> Geophysical Log(a) .7 r 3 0 IA'VJL �t rG K f� C/ha `-"+�(a�Gt- lam" <br /> SodtWaler Chemical Anatysae t3 <br /> ADDRESS CITY JJ Fyy� 7STATE - �} ZIP <br /> Other av 11 [ nL <br /> ATTACH ADDITIONAL INFORMATION (F rr EXISTS stoned wL LD"LL"4"U,,0" SENTATI ORTf SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 7 go IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />