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rJUADRUPLICATE STATE OF CAI.IFOBNIA QWR USE ONLY DO NOT FILL 1 <br /> For Local Requirements WELL COMPLETION REPORT <br /> i Page/of I %W Refer to Instruction Pamphlet STATE WELL NOJSTATION NO. <br /> Owner's Well Na. !rf ` ' �`fq Na. C G p11 <br /> Date Work Began f,l f/'/i Ended f !�/��� J 5 D LATITUDE LONGITUDE <br /> / �.� <br /> Local Permit Agency !^ f. r , ' 17 1. r is o.h <br /> Permit No. r (/r W Permit Dale A- APNITASIOTHER <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Name I I/I' ✓` Ir <br /> DEPTH FROM I DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address <br /> / r <br /> suRFacE DESCRIPTION .���1���� ��� <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STA ZIP <br /> WELL LOCATION <br /> Address <br /> _ _ City <br /> County <br /> APN Book Page Parcel <br /> Township Range Section <br /> qor <br /> Latitude INORTtt Longitude wesT <br /> � V Y—� r t 1 ' r �1 rd <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> /p / LOCATION SKETCH ACTIVITY (:) <br /> 1 f 4 ! NORTH <br /> r / NEW WELL <br /> MODIFtCAT1ON/REPAIR <br /> Deepen <br /> —other(Specify) <br /> ) <br /> V! <br /> DESTROY(Describe <br /> Procedures and Matenafs <br /> 4 ,) k Under"GEOLOGIC LOC,"J <br /> �. r N PLANNED USES) <br /> ut �. r ('') <br /> 1 W MONITORING <br /> � 1 <br /> WATER SUPPLY <br /> i <br /> � <br /> Domestic <br /> � Public <br /> i r 4 <br /> Irrigation <br /> *-ay <br /> Industrial <br /> .TEST WELL" <br /> r J <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads.Buildings,Fences.Rivers,etc. <br /> PLEASE HE AGGURATE & COMPLETE.DRILLING <br /> ./ <br /> METHOD e�f-�„ F+f t 1 r' E/tFLUID <br /> WATER LEVEL & YIELD OF G�'OMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING �T (Feel) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a wells Iong-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- WTYPE ._t1L FROM SURFACE TYPE <br /> HOLEINTERNAL GAUGE SLOT SIZE <br /> DIA. MATERIAL! CE- BEN- <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONITt: FILL FILTER PACK <br /> Ft. to Ft. (Inches) THICKNESS (inches) Ft. to Ft. (TYPEiSIZE) <br /> r <br /> L-------L... -----------i <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> — Geologic Lop <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief.Well Construction Diagram NAME 1 f f� h V`� If <br /> — Geophysical Log(s) <br /> (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> �.// <br /> Soi(lWater Chemical Analyses i y z"I x "�(- �1f Vrl ~`T <br /> ADDRESS � CITY STATE ZIP <br /> Other ,.1I // <br /> ATTACH ADDITIONAL INFORMATION. IF 1T EXISTS. Signed ��9T .R11 <br /> 1..Z �'.S'#� r�I��I' <br /> 11 WE DRILLERD REPRESEN THE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REQ',7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />