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-11.— .4r . , , , t <br />File with DWR WELL COMPLETIONREPORT <br />Page ` <br />of •-"' Refer to Instruction Pampblet <br />Owner's Well No M W-9 NO 525911 <br />Date Work Began 0 1 ta , Ended- ell <br />L_I I I f 1- f �_ % I I <br />i # <br />STATE WELL NO /STATION NO <br />LATITUDE LONGITUDE <br />av,aSilf ML. - alk t brOtl>, <br />A r r <br />Local Permit AgencyQ K <br />OMER <br />Permit No © 1:9 00 y Permit Date 2 2 <br />GEOLOGIC LOG WELL OWNER <br />ORIENTATION (! ) <br />DEPTH FROM <br />SURFACE <br />Y VERTICAL _ HORIZONTAL — ANGLE _ (SPECIFY) <br />DEFM TO FIRST WATER S.y (FL) BELOW SURFACE <br />DESCRIPTION <br />Describe material gram fixe, calor, etc <br />I.' <br />CITY W E L <br />Address 10 ( w St ileA- <br />LOCATION STATE ZIP <br />e_m!am "V%c <br />av,aSilf ML. - alk t brOtl>, <br />/� <br />l�r 16.5' <br />16. <br />%AE F`rt <br />c <br />•r7 I � � I <br />t Y <br />I , <br />Pi1ld Sita Y 4tAi` <br />31 0 as ' <br />f 1 ,. ri f YOB <br />C)4,+14l LL0 3`►',1y,bi <br />:3'7.0 <br />HOLE <br />DIA <br />5 i L 5 S M " i IL tf0ij 1nCr- <br />.0 <br />:Ian 51 4 >- - v wh <br />47.5 <br />-7. ' 91,0 <br />CE BEN FILTER PACK <br />MENT TONITE FILL <br />Y VERTICAL _ HORIZONTAL — ANGLE _ (SPECIFY) <br />DEFM TO FIRST WATER S.y (FL) BELOW SURFACE <br />DESCRIPTION <br />Describe material gram fixe, calor, etc <br />Namey-oy% 1 ro&.L ✓� �- <br />Mailing Address P. r0. B ox 6004 _-- <br />Sri`^ 9,� oo C� 0)4M <br />CITY W E L <br />Address 10 ( w St ileA- <br />LOCATION STATE ZIP <br />e_m!am "V%c <br />av,aSilf ML. - alk t brOtl>, <br />DEPTH <br />FROM SURFACE <br />%AE F`rt <br />City <br />County S_ a" JQUIAJ�Vl <br />AP Book Page parcel �� z <br />Township Range Section <br />Lat►tude _ I I - NORTH Longitude. I I WEST <br />DEG MIN SEC DEG M[!1 SEC <br />4)— <br />LOC%TION SKETCH ACTIVITY (4)— <br />NORTH <br />NORTH NEW WELL <br />^P/2MODWICATION I REPAIR <br />r _ Deepen <br />m 11 � Othm (Spe[,ly) <br />�'' Mid :21, Z <br />i DESTROY (> Procedures and Materia ls <br />tTI 1� Under GEOLOGIGLOG <br />t Y <br />tvVt e Lr <br />Pi1ld Sita Y 4tAi` <br />+70 CO <br />f 1 ,. ri f YOB <br />C)4,+14l LL0 3`►',1y,bi <br />11 tt <br />HOLE <br />DIA <br />5 i L 5 S M " i IL tf0ij 1nCr- <br />l L ► + W't <br />:Ian 51 4 >- - v wh <br />Y(7 v% ` n <br />tj;< <br />`._s r.�n`.,.o�l <br />V, .- t <br />I" e_ ( <br />( L <br />f 2,0 2,5 ' l U L S'c <br />l02. 3.0 G 6� <br />t <br />63.0 :69,0 <br />, I <br />I , <br />I I <br />TOTAL DEPTH OF BORING' `! (Fi!cus) ^ <br />TOTAL DEPTH OF COMPLETED WELL _ 6 .0 (Feet) <br />Vi <br />lig 1 bfcL � 1oil <br />brown, 3 Wl <br />�I <br />1; <br />�nr�N �NNC <br />n <br />r SOUTH <br />Illustrate or Descnbe Distance of Well from Landmarks <br />such as Roads Butldmgr Fences Ricers etc <br />PLEASE BE ACCURATE lr COMPLETE <br />-PLANNED USE(S)- <br />MONITORING <br />WATER SUPPLY <br />Domestic <br />Public <br />Imgauon <br />Industrial <br />TEST WELL <br />l ATHODIC PROTEC <br />T1ON <br />OTHER (speedy) <br />DRILLING HQiLOW S I EM_ AUGEQ FLUID —TP <br />DRILLING <br />METHOD <br />WATER LEVEL & YIELD OF COMPLETED WELL <br />DEPTH OF STATIC F 5" I <br />wATER LEVEL t _(Ft) & DATE MEASURED <br />ESTIMATED YIELD (GPM) 3 TEST TYPE <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br />e May not be representative of a well's long -terns reld <br />— Geologic Log <br />Well Construction Diagram <br />_ Geophysical Log(a) <br />Soil /Water Chemical Anstysss <br />_ Other <br />ATTACH ADDITIONAL OYFORAPAM)M F IT EXISTS. <br />DWR 188 REV 7 90 <br />I, the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br />NAME Gt Tr - AY&I %d IVC - <br />(PERSON FUX OR CORPORATION) (TYPED OR PRINTED) <br />67 7 S ItR A cr `:!i V L t N �4 L(5-6 <br />ADDRESS CIfY STATE ZIP <br />t <br />signed^_ �z ai . wul 031121/" -120901 <br />IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />CASINC(S) <br />DEPTH <br />ANNULAR ;MATERIAL <br />DEPTH <br />FROM SURFACE <br />BORE <br />FROM SURFACE <br />TYPE ✓ <br />TYPE <br />HOLE <br />DIA <br />W zF <br />INTERNAL <br />MATERIAL/ DIAMETER <br />GAUGE <br />OR WALL <br />SLOT SIZE <br />IF ANY <br />CE BEN FILTER PACK <br />MENT TONITE FILL <br />Ft to Ft <br />Onchee) <br />Q, J <br />GRADE (Inches) <br />THICKNESS <br />(Inches) <br />Ft to Ft <br />(TYPE/SIZE) <br />t7 S� d <br />VC <br />t{O <br />O ! <br />o <br />V <br />O <br />.02 <br />j 0 O <br />3. O' S <br />LontS z <br />— Geologic Log <br />Well Construction Diagram <br />_ Geophysical Log(a) <br />Soil /Water Chemical Anstysss <br />_ Other <br />ATTACH ADDITIONAL OYFORAPAM)M F IT EXISTS. <br />DWR 188 REV 7 90 <br />I, the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br />NAME Gt Tr - AY&I %d IVC - <br />(PERSON FUX OR CORPORATION) (TYPED OR PRINTED) <br />67 7 S ItR A cr `:!i V L t N �4 L(5-6 <br />ADDRESS CIfY STATE ZIP <br />t <br />signed^_ �z ai . wul 031121/" -120901 <br />IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />