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File with•DWR ELL COMPLETION REPORT A61i I I i I I <br /> Page_t_Of-i— 4f <br /> Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. w '�' ' No.9JA 525871 0 <br /> LATITUDE LONGITUDE <br /> Date Work Began , Ended U � �, H�ZA` u <br /> .Local Permit Agenc �^ 1� <br /> Permit No. A. Permit Date 1119 4 1 g 9 QP <br /> GEOLOGIC LOG WELL OWNER 0r- CM <br /> ORIENTATION ('�) VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name'T0 S C'O ���� <br /> PAW <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address / 1I� <br /> DEPTH FROM Q ®M0►/ C-A q +�] <br /> SURFACE DESCRIPTION ["t,C3a cRr:.)^1. <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ' ZIP <br /> WELL L CATION <br /> " Address ® MME13L 1-- R NL <br /> City <br /> C <br /> 0 ,LL <br /> County <br /> APN Book Page Parcel <br /> MRS D1:3 -5-rEL0*�yC_1_D Ed Township Range Section <br /> or <br /> ' t , C-1 �� Latitude DEG. ' MIN. I SEC. NORTH Longitude WEST <br /> DEG. ' MIN. ' SEC. <br /> LOCATION SKETCH ACTIVITY (.:L) <br /> NORTH — NEW WELL <br /> 4 E <br /> S E� ^ T A �r, e ^ MODIFICATION/REPAIRAIR <br /> r-� i t1^t`- `Y) <br /> i —Deepen <br /> , <br /> W <br /> � 1 `T' —other(Specify) <br /> tJ 1� <br /> i �" 1 1 M -�. a <br /> (� _XProc dur (Describe <br /> Procedures and Materials <br /> ' Under"GEOLOGIC LOG") <br /> PLANNED USE(S) <br /> W MONITORING <br /> i <br /> 1.� 1 WATER SUPPLY <br /> t( _ {' Domestic <br /> 1. - 3 — Public <br /> — Irrigation <br /> *+• K <br /> , 1 <br /> — Industrial <br /> ' ..TEST WELL" <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 /> F1 LTEB S Mfg PLEASE BE ACCURATE ds 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 a well's long-term yield. <br /> CASING(S) DEPTH ANNULAR ;MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE _ <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA. W & MATERIAL/ CE- BEN- <br /> (Inches) a ie s� s GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. H v (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE SIZE) <br /> , <br /> , <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> _ Geologic Log I,the WD o f2WftR� PRI LLI L)Gt CO <br /> — Well Construction Diagram NAME(PERSON FIRM, OR CORPORATION)(TYPED OR PRINTED) <br /> — Geophysical Log(a) P`®► ox 330 POO V STA CA 9 � <br /> _ t Chemical Anely gst�al' <br /> �. Outer Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL dVFORMATlOM F R EXISTS. Signed ®® <br /> WEU DRILLER AUT RIZED PRESS DATE SIGN C•57 LICENSE NUMBS <br /> IDWR)88REV.7.90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY N- EF&D FORM <br />