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ORIGINAL S1 1TE OF CM I I OHNI 1 D W R U O N Y — D N T F t L IN <br /> File with DWR WELL COMPLETION REPORT . r <br /> Page--__„_ of Re(er to Instrrunon Pamphl,t STATE WELL NOISTATION NO <br /> Owner ti Well X30 _ N o 118 f <br /> TtE Work Beginr ended `-L'f % LATITUDE LONGITUDE <br /> I nca] Permit Agency?'ct <br /> . Pcrmit No Permit Date�Ilf. "���_ APN)TPSiOTH R <br /> GEOLOGIC LOG iti'ELL OWNER <br /> ORIENTATION ) <br /> (�) — VERTICAL _ HORIZONTAL —ANGLE —(SPECIFY) Name r 7r j <br /> DEPTH FROM <br /> DEPTH TO FIRST W ITER �^� ss(FI) REI OW SURFACE Mailin ddre <br /> ..._—,._.�.....�..+.:,. ,— ._. <br /> SURFACE DESCRIPTION �•.=;_P�A ,_r; <br /> 1]eSC1T17P material grain size color etc f CITY � STATE ZIP <br /> Ft to Ft _ ii ELL LO �1T OY <br /> / I <br /> Address ~' •• •_+ <br /> ' City ' <br /> �- <br /> ' APN Book _ 7 PageParcel 6: . <br /> f <br /> r 3' Township Range—__-e_ Section <br /> L! ° Latitude_ r NORTH <br /> Longitude DEG <br /> J - DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (!)— <br /> NORTH _ NEW WELL <br /> t'/ MODIFICATION!REPAIR <br /> Deepen <br /> —Other(Specay) <br /> 01 <br /> DESTROY(Descnbe <br /> t'rocedures and Materials <br /> ' Under GEOLOGICLOG)I <br /> I- PLANNED USE(S), <br /> 3: e MONITORING <br /> WATER SUPPLY <br /> r i <br /> Domestic <br /> - Irn98t+en <br /> r <br /> Industrial <br /> i <br /> TEST WELL <br /> CATHODIC PROTEA I <br /> SOUTH rION <br /> Illustrate or Descrt6e DlstanLe of Well from Landmarks ...— OTHER(Specify) <br /> such as Roads Buildings Fences Rovers etc <br /> PLEASE BE 4CCL+RATE & COMPLETE <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL & YIELD 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 e-veil's long-term yield <br /> DEPTH CASINGS) DEPTH <br /> ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE CE BEN <br /> (inches) Ta_Nl <br /> oi� t MATERIEL/ DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to F[ (Inches) THICKNESS (Inches) Ft to Ft MENT TDNITt FELL <br /> r ' <br /> (2L) <br /> ATTACH1*IFNTS (✓) CERTIFICATION STATEMENT <br /> Geologic Log I the unde Igned c rMy thattPIs repo I3 complete and accurate to the best of my knowledge and belief <br /> — Well Construction Diagram NAME s •' <br /> (PEMN FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> SodlWdter Chemical Analyses f, `�/r T 3,? 7 <br /> Other �- <br /> ADDRESS _ CITY f SSlIATE ZIP <br /> j r... <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed f CJ <br /> LL: WELL DR LLER AUTHORIZED REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> Uwil 11119 m v; Af IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />