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ORIGINAL 5T\TE OF CAI IFOI1\1A DWR USE ONLY - DO NOT FILL IN <br /> File with DWRWELL COMPLETION REPORT <br /> Rr frr 1`0Irnfrrrf rnnr Prt utlrlrlcl STATE WELL NOISTATION NO <br /> 1?ige_I,_ ��El <br /> QRIiei S `.��e u ll NO `� ��� No 729663 LONGITUDE <br /> LATITUDE <br /> I],ttE «oil. 13f�ltl � CD I✓nciEEl S 6 � 1 p <br /> r 1. �'L. I I <br /> rcnrvl <br /> •LUC,II PElltllt ��fTli\ ` V' i APNTRS107HER <br /> Pclmlt \o OCA suit _PLIinit Dlte 3 � <br /> GCOLOCIC LOG «LLL O\►\LN <br /> ORIENTATION (�) !VERTICAL —HORIZONTAL —ANGLE (SPECIFY) <br /> N. lIl1C 7 <br /> DRILLING �[alllnU �ddl +ss �� 2 1 �C,)Lr� <br /> �G❑EPTH FROM METHOD FLUID " l '+ V G <br /> $URFACE DESCRIPTION CITY l STATE ZIP <br /> FI 'o Ft Dc%c)tbc matcrud _,,rain si-i falm tic <br /> 21S E I LO TI <br /> i i � I -\CIEIIf�S <br /> 1� t r\0. <br /> Q Clt\ n <br /> !.v Count\ a1n O�C1 fl ✓� <br /> 1P\ Book P tt(c P,tt EL I <br /> To\%ilskip Ball,( SLCt7Iffl <br /> i L,itltiide NORTH <br /> DEG MIN SEC DEG hall SEC <br /> LOCATIO\ SkETCII ACiINIII r <br /> i r NORTH -1/_ r EW JELL <br /> t1CDIFICATVOr, <br /> ,.(• Demme-^ ! <br /> V) Gtr e <br /> i <br /> r r <br /> DESTROY rDe,c C= <br /> L'nCer DECLOG C = I <br /> �1 v L) PL\\\LD t,SI ti r <br /> �+ ".,TER SIL—L+ <br /> LyF <br /> 1-iI er to <br /> flOr ITOR'I ` <br /> TEST IELL <br /> CATHODIC PROTECTIC^ <br /> HEAT EXC�A r.E .r <br /> 111RICT PUS_ <br /> INJEC-10, <br /> t VAPOR E{TRA,-IC+ .�._ I <br /> SOUTH RENIEM-TIG — ' <br /> i t lllushr', r,r Utecrlbr 2)I+trr,re, nj It'll fi,n,I Lnrsls baflelm-, <br /> &ilcc) Rilcr1 If( ❑ic(Pflnclr f!M t' P 11P.'Til)hr)h r !f OTHER ISPs CIF�, <br /> ,Icerssr,rf P1FASE BE ACCLRA1?E COIPLFTF <br /> I <br /> \1ATER LEAEL & IIELD Of COMPLETLD «LLL <br /> I I <br /> DEPTH TO FIRST WATER (F I BELOW SURFACE <br /> i I ' <br /> DEPTH OF STATICL q I.�(� f -7/U7) <br /> 1 ' WATER LEVEL (Ft)&DATE MEASURED ._. <br /> ' ESTIMATED YIELD (GPIA) & TEST TYPE f <br /> 101 li DI PI II OF 110111\( 1 2d Ftit TEST LENGTH (His) TOTAL DRAWDOWN! (F1l <br /> 101 Al DF 11Tl l OF C oMPI FTI 1) 15 1-LL f Z 1 fe t Un not k iepl, tntati 1 of a til, lural-o w 11 Irl <br /> DEPTH CASI\C (SI DEPTH A\\L l AK �I Al E kiI AI <br /> FROM SURFACE BORE HOLE TYPE (-) FROM SURFACE TYPE <br /> DIA x E = a MATERIAL J INTERNAL GAUGE SLOT SIZE CE °EN FILTER <br /> (Incnesl a w �� a GRADE DIAMETER OR WALL IF ANY MENT TCN'TE FILL {TYPE S Z=- <br /> Ft <br /> � <br /> Ft la Ft n U o 5 (Inches) TrilCKNESS (Inches) Ft to Fi { � ) ( � ) - <br /> o ,� <br /> !Q 8 vc lc�� 1 <br /> !v 20 v(1 d X1,0 20 �, I?G 8 <br /> l <br /> I <br /> I <br /> I <br /> , <br /> ATTACIIME\TS {�) CERTIFICATIO\ SF�ATEME\T <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> — Geologic Log U i <br /> Well Construction Diagram NAME(PERSON FIRA OR ORPORATIONI (TYPED OR!PRINT 1 I <br /> Geophysical Log(s) v 3 ` \� }o IV Is� CA <br /> SoilJWater Chemical Analyses b <br /> ADDRESS Y STATE ZIP <br /> p <br /> Other "7-t 7 10-V7-i <br /> ATTACH ADDITIONAL WFORMATION IF 17 EXISTS S,gned $ PATE SIGNED C�7 LIC£N�E NL,r E-7 <br /> — <br /> IF <br /> RILLERlAIJTHORI2ED SEN TIME <br /> raw II ,ti, lit\ t l a IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />