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ORIGINAL
<br />File with DWR J
<br />Page J_ of _
<br />Owner's Well No .
<br />Date Work Began.
<br />• Local Permit Ag
<br />' Permit No —
<br />ORIENTATION (! )
<br />DEPTH FROM
<br />SURFACE
<br />Ft to Ft
<br />,
<br />,
<br />r '
<br />2q, S 2.0
<br />32.0 3 ,0
<br />H 3 J
<br />,
<br />i
<br />S_'I�r .O
<br />6210;65-,o '
<br />�11iL UI � (111011\i1
<br />WELL COMPLETION REPORT
<br />Refer to Instruction Pamphlet
<br />199- 525910
<br />Ended
<br />Permit Date—
<br />GEOLOGIG LOG
<br />VERTICAL _ HORIZONTTArAL�� n— ANGLE _ (SPECIFY)
<br />DEPTH TO FIRST WATER 2�(FL) BELOW SURFACE
<br />DESCRIPTION
<br />Describe material, grain nze, color, ere
<br />1 1,1 1 _ _ . _II __ _ ,L IT-.--. ,._
<br />MP s _• M
<br />. ,
<br />Paz a T M, MN, MAMA
<br />- �J��1�1✓�
<br />Ifff
<br />kA y
<br />-L L
<br />_ irrigation
<br />y�_ K,r
<br />�Q
<br />ANNULAR MATERIAL
<br />aVIId ,
<br />(Sw -
<br />Cd
<br />1Ia.LYt
<br />,[
<br />; CL 14L
<br />A
<br />L L- ML — i,(`
<br />CE BEN
<br />ME?NT TONITE FILL FILTER PACK
<br />!;av,46M_v-UAt
<br />Y- w1 v%
<br />4,% 4 Sb!
<br />TION
<br />Illustrate or Desenex Distance of Well from Landmarks
<br />U in
<br />7l LT � `•• U �Lf
<br />such as Roads ousedings Fences Riom etc
<br />S
<br />�z
<br />PLEASE BE ACCURATE tr COMPLETE
<br />%� Yt
<br />a"
<br />eLi s
<br />L SC
<br />METHOD FLUID
<br />(�) (�) (�) (TYPE/SIZE)
<br />TOTAL DEPTH OF BORING 67 `-' (Feet)
<br />TOTAL DEPTH OF COMPLETED WELL i5S Q (Feet]
<br />STATE WELL NO /STATION NO
<br />LATITUDE LONGITUDE
<br />WELL OWNER
<br />Name �.v y c-V'r't�M ?jr0 ,L,,I
<br />Malang Address P. 0- D oX 0 0
<br />54 --in � � CQ Ru58�
<br />CITY STATE ZIP
<br />WELL LOCATION
<br />Address 341 W e5+ {L.ei �2wti u LOL►n� -
<br />t
<br />City—
<br />County –Sat, QQ O A"
<br />APN Book Qui '—;'Page t es_ Parcel O2–
<br />Township Range Section
<br />Latitude _ AEG ' MIN I SEC NORTH Longitude _ DEG 1 MW SEC WEST
<br />LOCATION SKETCHACTIVITY (: )—
<br />NORTH U/- NEN! WELL
<br />`U/ e
<br />F IPr - — 'y r MODIFICATION/REPAIR
<br />Deepen
<br />Other (Speedy)
<br />- La atn _ 2,v M�4'3
<br />va
<br />DE5TROY (Describe
<br />Procedures and Marenals
<br />Under GEOLOGICLOG )
<br />PLA`, ED
<br />USE(S)-
<br />MONITORING
<br />WATER SUPPLY
<br />Domestic
<br />Pebho
<br />tT>-EM►e off Nim
<br />_ irrigation
<br />y�_ K,r
<br />�Q
<br />ANNULAR MATERIAL
<br />_ Induslnai
<br />BORE
<br />BORE
<br />DEPTH
<br />FROM SURFACE
<br />TYPE �
<br />t
<br />S reed
<br />TEST WELL
<br />c.AAae (-%
<br />CE BEN
<br />ME?NT TONITE FILL FILTER PACK
<br />CATHODIC PROTEC
<br />SOUTH
<br />W
<br />TION
<br />Illustrate or Desenex Distance of Well from Landmarks
<br />SLOT SIZE
<br />IF ANY
<br />OTHER (Specity)
<br />such as Roads ousedings Fences Riom etc
<br />Ft to FI
<br />PLEASE BE ACCURATE tr COMPLETE
<br />y v
<br />Unches)
<br />DRILLING N
<br />GES
<br />(Inches)
<br />METHOD FLUID
<br />(�) (�) (�) (TYPE/SIZE)
<br />WATER LEVEL h YIELD OF COMPLET°D
<br />WELL
<br />DEPTH OF STATSC C[ b
<br />WATER LEVEL ,�- (Ft) d DATE MEASURER _ /
<br />ESTIMATED YIELD* (GPM) d TEST TYPE
<br />TEST LENGTH (Hrs) TOTAL DRAWDOWN
<br />(Ft,)
<br />' May not be representative of a well's long-term yield
<br />ATTACHMENTS (� )
<br />Geologic Loa
<br />Well Construction Diagram
<br />c r
<br />Geophysical Log(a)
<br />Sail Water Chemical Analyeea
<br />Other
<br />f; 1 t Y A r t
<br />1, the undersigned, certify that this report is complete and accurate to the beat of my knowlodge and belief
<br />N.4MF E R— RYfiN JN
<br />(PERSON. FIRM, 09 CORPORATION) (TYPED OR PRIMED)
<br />6?,�7 ' t-mCf- e LLt.\ CA-
<br />q�cs6�
<br />ADDRESS�j CITY STATE
<br />mss' tP,,. ` _ �' 1 W �r►•ll�� 1��
<br />KW/2/1,7 '?2090
<br />ATTACFt ADDITIONAL IAFFORMA77ON IF rr EA73r8j I " " LL 0MU,EA AUTHORIZED REPRISE ATIYI 3 • D,
<br />nwn 7 qA R F V 7 no
<br />IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM
<br />ANNULAR MATERIAL
<br />DEPTH
<br />FROM SURFACE
<br />BORE
<br />BORE
<br />DEPTH
<br />FROM SURFACE
<br />TYPE �
<br />TYPE
<br />CE BEN
<br />ME?NT TONITE FILL FILTER PACK
<br />HOLE
<br />W
<br />INTERNAL
<br />MATERIAL/DIA GRADE DIAMETER
<br />GAUGE
<br />OR WALL
<br />SLOT SIZE
<br />IF ANY
<br />Ft to FI
<br />Cloches)
<br />y v
<br />Unches)
<br />THICKNESS
<br />(Inches)
<br />Ft to Ft
<br />(�) (�) (�) (TYPE/SIZE)
<br />ATTACHMENTS (� )
<br />Geologic Loa
<br />Well Construction Diagram
<br />c r
<br />Geophysical Log(a)
<br />Sail Water Chemical Analyeea
<br />Other
<br />f; 1 t Y A r t
<br />1, the undersigned, certify that this report is complete and accurate to the beat of my knowlodge and belief
<br />N.4MF E R— RYfiN JN
<br />(PERSON. FIRM, 09 CORPORATION) (TYPED OR PRIMED)
<br />6?,�7 ' t-mCf- e LLt.\ CA-
<br />q�cs6�
<br />ADDRESS�j CITY STATE
<br />mss' tP,,. ` _ �' 1 W �r►•ll�� 1��
<br />KW/2/1,7 '?2090
<br />ATTACFt ADDITIONAL IAFFORMA77ON IF rr EA73r8j I " " LL 0MU,EA AUTHORIZED REPRISE ATIYI 3 • D,
<br />nwn 7 qA R F V 7 no
<br />IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM
<br />
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