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QUADRUPLICATE S 1 A rL OF C ALIFORM]1 DWR USE ONLY — DO NOT FILL IN <br /> For-Local Requirements OLL COMPLETION REPOR <br /> Page of , t <br /> Rl fr r 1n Instl+tctton Yarnphlr t STATE WELL NO/STATION NO <br /> Owneris 1Vell INo }_ ! <br /> r 3 LATITUDE LONGITUDE <br /> t No <br /> Datc �N of k Began Isndcd f <br /> Local Pcnntt A , ncs -7—fr <br /> ! — L' APNITRSlOTHER <br /> Pct rott No cPEI)nit Date <br /> GEOLOGIC LOG F WELL Off►"VER <br /> ORIENTATION (�) _VERTICAL —HORIZONTAL _ANGLEN,1111( <br /> t ) # r f <br /> _(SPECIFY) �',.ill]f <br /> r <br /> nMETHOD � � FLUID Mailing AIddicss � <br /> DEPTH FROM f <br /> SURFACE DESCRIPTION <br /> Ft to Ft Dc srlthr wetrrint a)atn tl:r rulor rte CITY STATE ZIP <br /> I WELL LOCATION <br /> I I <br /> Add]c SS <br /> lC.oia my <br /> APN Book Pagc Pat cc] <br /> IrnsnshTp] RTnge 5cctton <br /> L ttttndc I I NORTH Longttudc I WEST <br /> i DEG MIN SEC DEGN SEC <br /> LOCATION SKETCH l`,'ITI (�) <br /> r NORTH N <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> I I t _ Deepen <br /> — Other(Specify) <br /> I DESTROY(Describe <br /> i 1 1 <br /> Proved Under <br /> es and Materials <br /> r Under GEOLOGIC LOG) <br /> J PLANNED USES (zL) <br /> I I ' WATER SUPPLY <br /> _ Domestic _ Public <br /> Irrigation — Industna <br /> to <br /> Lua MONITORING <br /> 3 I TEST WELL <br /> I I CATHODIC PROTECTION <br /> i I HEAT EXCHANGE <br /> DIRECT PUSH <br /> I I <br /> INJECTION _ <br /> VAPOR EXTRACTION I <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Il1ilsNntr or Druribc Disttuar of 111th{runt Roads Bntlrlur(s <br /> I p 1 rncrs HiLcrs rte nail atttah a rntr7� I se addlttona(j)npu f OTHER(SPECIFY) <br /> II<crsvinf PIPASEREACCURAT�.�.COM1IPIFTF <br /> NATER LEVEL & YILLD OF COMPLETED WELL <br /> I <br /> i I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> I I ESTIMATED YIELD (GPM) & TEST TYPE <br /> 10TAL DI;P111 ()1 80111\17 (Fcct) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DENT H OF CONIPLP TED N1 P L1 (Fr(t) *May not he repterentatrve of a u11' long-te77n yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HORS TYPE(2L) FROM SURFACE TYPE <br /> NIA r w o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BE <br /> (Inches) z Q zov a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ftm � THICKNESS (Inches) <br /> ) Ft to Ft ( � ) (� ) (� ) (TYPE/SIZE) <br /> I I <br /> I <br /> I I <br /> I <br /> I I <br /> I ' <br /> j(TTACHNIENTS (�) CERTIFICATION STATEMENT <br /> / 1 the undersigned certify that this report Is complete and accurate to the best of my knowledge and belref <br /> —..!Geologic Log <br /> 1 Well Construction Diagram NAME t ' _ <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> SOLI ical Log(s)r <br /> Soil/Water Chemical Analyses <br /> Other) ADDRESS CITY STATE ZIP <br /> � <br /> ATTACH ADDITIONAL INFORMATION IF IT FXISTS Signed I <br /> WELL URILLERlAUTHORIZEO REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> nU It Itis ITIS H r)- IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />