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STATF OF (:ALlFOTtN)A W R <br /> ONLY O N T FILL II' <br /> QUADRUPLICATE WELL COMPLETION REPORT STATE WELL NOJSTATION NO. <br /> For cal Re trerments Refer to Insrracrion Pamphlet n <br /> 1j", OI l�I .- --- N0• 5 5 ` 4 3 LATITUDE u LONGITUDE <br /> Owner's Well No. <br /> Date Work Began En ed <br /> A tlll „ �rG <br /> [7l� l� <br /> Local Permit Agene r^ permit Date � ” <br /> Permit No. i WELL OWNER r <br /> G 'dLOGIG LOC IV (, 'c111d� <br /> HORIZONTAL —ANGLE (SPECIFY) Name r / <br /> ORIENTATION (!} VERTICAL � L <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address } <br /> DEPTH FROM DESCRIPTIONSTAT 1 r IP <br /> SURFACE <br /> CITY W E L Lo TION <br /> FE ­ t_ <br /> I�ermbe•material, imsrze,color,etc.a <br /> 1 Address <br /> 11 City .. / <br /> r&t1j jr/i II 1 rnlnly d L <br /> APN Book Page Parcel <br /> or <br /> Township Range Section <br /> r r °' WESr <br /> �`/� j Latitude NORTH Longitude <br /> DEG, MIN. SEC. DEG- MIN. SEC. <br /> 111 LOCATION SKETCH ACTIVITY (2L)— <br /> NORTH <br /> 2L)NORTH NEW WELL <br /> MODFICATIONIREPAIR <br /> Deepen <br /> i <br /> Other(Specify) <br /> DESTROY(Describe <br /> Proeedurae and Materials <br /> Under"GEOLOG)CLOG'7 <br /> PLANNED USE(S) <br /> W {�! <br /> a MONITORING <br /> i <br /> 1 � WATER SUPPLY <br /> I <br /> Domestic <br /> s <br /> �+ — Public <br /> I <br /> I _ Irrigation <br /> _ Industrial <br /> 1 <br /> ..TEST WELL" <br /> SOUTH — CATHODIC PROTEC- <br /> TION <br /> Illasfrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> I I <br /> PLEASE BE ACCURATE & COMPL TE. <br /> DRILLING <br /> METHOD FLUID <br /> ATER LEV L & YI -LD 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 (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) ' May not be representative of a wells long-term yield. <br /> DEPTH CASINGS) ANNULAR MATERIAL <br /> FROM SURFACE HORE- DEPTH <br /> LE TYPE FROM SURFACE TYPE <br /> DIA. z MATERIAL! INTERNAL GAUGE SLOT SIZE BEN <br /> (Inches) zo� J GRADE DIAMETER OR WALL IF ANY ME CE- TONITE FILL FILTER PACK <br /> Ft. to Ft. coo LL (inches) THICKNESS (Inches) Ft. to Ft. ✓ (TYPE/SIZE) <br /> I {-1 (—) {-1 <br /> 1 <br /> \ � t <br /> 1 I <br /> I <br /> ATTACHMENTS (IL) CERTIFICATION STATEMENT <br /> — Geologic Log I,the undersigned,certify that this/report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME �? f L./ f I/ <br /> y Geophysical Log(s) (PERSON, FIRM, OR COR <br /> /PJ�q/�4TION) (TYPED OR PRINTED) \/ <br /> Soil!Wsler Chemical Analyses /C <br /> ADDRESS Other CITY STATE ZIP <br /> IV <br /> ATTACH ADDITIONAL fNFORMATlON. !F!T EXrS75. Signed `� <br /> IL _%WC DRILL R A H IZED REPRESFNTATIYE DAT SIG LD C-57 LICEN E NUMBER <br /> DWH 188 REN.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />