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TiRrMICATE STATE. OF CALli' i\')A -D W R USE ONLY — DO NOT F I r N <br /> • otinep's Cop �LIELL COMPLETION REPORT <br /> Page PagOF Refer co lurtrurtion Pan1p1•ler STATE WELL NO/STATION NO. <br /> 0-11vii 11'ell No. I vv l if a I IEl I <br /> 1)111(' Work 13e1 aN r rd 550 <br /> v LATITUDE LONGITUDE <br /> Local Pei Agerr�c <br /> PCTinit No. Yrrrn it 1):111° �`� APN1 1 Tr R <br /> ( iol'i I,QC N'1,;1111 O►V�f\N,Eli <br /> ORIENTATION (/ I _ VERTICAL — HORIZONTAL ANGLE (SPECIFY} ;11!11' �'r ` ✓ ' •`f�^•r �r ` r <br /> 1)]"I'll TO EIIi.S"F 11',1'17,1___ _ iPl.l iSFa,r)55' til`RhA[7: \f;ll[In>; :111c1n•ss <br /> r ,, J �..� <br /> or <br /> DEPTH FROM <br /> SURFACE <br /> U F:ti(:R I],'I']() <br /> Fl. f0 F[.::] I)VS,7rbr rlarlerml,frail sme,fulur•c1 r. CITY STATE ZIP <br /> IS . <br /> (JLT <br /> C :r'Il ' <br /> -T ��----"' �I � l 11111,1[; _ I':l>;r' F(.4-1 <br /> �! [11�omlrilr li'l111l Si-0 loll <br /> I I.:It II II<Il' i f NORTH 1,1111k1111(1!' i WES <br /> EG. T <br /> DMIN. SEC. DEG MIN. SEC. <br /> LOCATION SKEI'CII ACTIVITY (�J <br /> ' NORTH NEW WELL <br /> r <br /> MOAIFICATIONfREPA1R <br /> Deepen <br /> —Other(Spaciry} <br /> —DESTROY(Descnbe <br /> Procedures and Malarials <br /> Lv Z Under"GEOLOGIC LOG") <br /> WV Q (�1 <br /> W MONITDRING <br /> WATER SUPPLY <br /> Domestic <br /> ` Public <br /> l I <br /> Irrigation <br /> Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TON <br /> 111estrrrfr•n1, <br /> 1311-ser",1)islanrr of It.,11 Jronr Landlnnrks — OTHER(Si <br /> 4111,11 as 1luadr,lfallrfing.y.F?'rices,Nitwrs.ale <br /> PLEASE BE ACCUlfAT-' d COM!'! .TE. <br /> DRILLING <br /> ' METHOD Mi^- FLUID <br /> NN,A'f1:H hi?Vlil, & 5' k:I,I OF CO 51PI.ETED I'li <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) 6 DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DErm OF 110[IINC (Feet) TEST LENGTH Mrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COA(P[.I:T1:V WI':LL (Feet) ' AI,jv'not be reprcrr',uati<c•of a j,c11'r long-term geld. <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE DOBE TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA z MATERIAL/ - CE B1:N <br /> (Inches) a i<I DIAMETER OR WALL YF ANY FILTER PACK <br /> c 1,c vu GRADE u MEN-TONITL FILL {TYPElSIZE) <br /> Ft. io F1. c.» (Inches) THICKNESS (Inches) Ft to Ft <br /> ) ('�) FI 1 <br /> ATTACHMENTS CERTIFICATION STATFNIE.NT <br /> I, the unders'gned,certify that this report is com tete and accurate to the best of my knowledge and belief_ <br /> — Geologic Log ,` <br /> Well Gonslruclion Diagram NAME <br /> V <br /> (PERSON RM.Geophysical LoDH CORP (IYPFD OR P5WLD) <br /> �. Logs) , <br /> I/f// <br /> — Soili Water Chemir_al Analyses J. •+� ~' <br /> ADBRESS CITY Jam / �, STATIL J//'-' ZIP <br /> Other / r' .• C7 i �/`' 61, l? <br /> ATTACH App1T[ONAlw INFORMATION 1F 1T EXISTS Sign ad <br /> i .LL DRILLER A INDRgED RCPR[SEfJPAIIVF DAT S1G LP C57 LICENSE NUMBER <br /> Dwulsnitt:v 7!1 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />