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a <br /> ORIGINAL, ;-4 A, STATE OF CAIJrORNu — DO <br /> Fire with QwJ WELL COMPLETION REPORT <br /> ,ePage2 of—2 Refer to Inrtruetlon Pampblet STATE w ND ISTARON ND. <br /> Owner's Well No -No /i ��`�r]S ���7 0 <br /> Date Work Began , Ended 4F v L LASE WNGITUnP <br /> Lond permit Agency <br /> Permit Na Permft Date e <br /> GEOLOGIC LOC ` ` WELL OWNER <br /> ORIENTATION (✓) ._YERIMAL ^NORIZomrAL � ANGLE �wearlY) Nalnq= 'T T1^Ilhk,j a <br /> 17EP71t FROM DEMTO FIST WAT911--_- (tt) ULOW SURVACE Mailing Addrem _ty` �• �- ` , <br /> SURFACE DIrSCR1PTION <br /> Ft colo,eta ' WELL <br /> T AI?CAT I O N Airme ZIP <br /> 332 ! 334 I Sand 4 \\Y 334 ,,t,�.. - - <br /> 3 7 / C a �- � f _ ;cvLlnniy ''"'` �} <br /> 337 -339 Fine $d R n •'t pN Book Y'age Parcel 4 <br /> ' a & �h a ' <br /> •• 'r` ToIsi� Range Scdion <br /> 1 � 1A � ,I.iiti eLd't's NaRr1t Lmlgitude- r__ a wlasr <br /> MIN SEC DE& MRN SEC <br /> LOCATION SKETCH <br /> • ACTIVITY (�) <br /> r ;` NORTH NEW WELL <br /> 1 1 t MODWICATIONIREPAIR <br /> t � � it ,oaepea <br /> s 1 - <br /> r Other(Speslty) <br /> `• DEMOY(Oesame <br /> r N WGCYfIVrNAedAtelfYr9ta <br /> tlader"DEOLOf#ICi.Op 7 <br /> ' r PLANNED USI3(8) <br /> Lu MOWTORM <br /> to <br /> 1 , <br /> 1 , <br /> WATER SUR'!Y <br /> 1 , <br /> Domestic <br /> Public <br /> 1 r <br /> 16gatm <br /> h <br /> IrrSaall <br /> t , <br /> ._. Iaduatriel <br /> r , <br /> 11118T WELL' <br /> 1 , <br /> t ' 80UTH imam HODIC PROtEC- <br /> ' ' ISrtttrate ar t7eacrid&ffnnDggts�starrar of Welf from Landmarks —GT11ER Capacity) <br /> such ds+ + PLEASE BE AC+l�URA�'P&LSOMPI.Ea'L <br /> 1 1 <br /> 1 + DRILLING <br /> METHOD FLUID - <br /> I , TREATER LEVEL & YIELD OF COMPLETED WELL <br /> t DEPTH OF STATIC <br /> WATER LEVEL (Ft) b DATE MEASURED <br /> r � <br /> ' ESMMATED YIELD' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (We) TOTfAL. DRAWDOWN M.) <br /> TOTAL DEPTH OF COWLLMI) WELL (Feet) •May mi be repramwi tie of a awUll long-terns yWd. <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE ROE TYPE •' FROM SURFACE TYPE <br /> DIA r, I� MATERIALI DMRNAL GAUGE WIT SIZE CE- 6Ehf <br /> Ft 10 Ft (inches) DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MENT TON FILL <br /> (taahas) THICKNESS ("so) Ft b Ft CFYPEft31zE} <br /> + <br /> k , <br /> r , <br /> 1 <br /> 'ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> Cleo'aslo Lag 1,the underelghedl certify that this report 1a rompiele and accurate to the heat Of my knowledge and betiet <br /> Well Conalruclton Olearam NAME• (PERSDN, } C RADRATgR)(TYPED OR.PRINTED) <br /> � Geophyercel Log(a) <br /> SolfrWater Chemical Anagraae <br /> Other ADURFM CITY STATE Ap <br /> —r <br /> ATTACH ADOMONAL MIFORPAATIQN IF Jr EXISTS Signed <br /> LMFLI DRILLER AUTIIt]RFIED RFfRFSENTAiRIE ER Cd7 LICENSF NUM6ER <br /> DWB 166 REV Z go IF ADDITIONAL SPACE IS NEIEDED USE NEXT CONSECUTIVELY NUMBERED FORM 017 ,3 <br />