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VT1ltalnsNL �,n��. w �,n,,,u vu,•rn <br /> File with DWR WELL COMPLETION REPORT <br />' ii 711 <br /> Page � of 1 Refer to Inrtrlrctson Pamphlet STATE WELL NO!STATION NO <br /> Owner's Well No ElM�►.1 No <br /> 561649 <br /> Date Work Began ab 16 Ended 9146176 LATITUDE LONGITUDE <br /> Local Permit Agency 5a-r% z, (amil Pvbtic Re-III ll s;rz 1 I I I 1_ I 1_ 1 I J--L <br /> Permit No 5V- W 101931 Permit Date 17116 <br /> r f R � <br /> 1 GEOLOGIC LOG y WELL OWNER j <br /> ORIENTATION (�) —ZVERTICAL — HORIZONTALL/�_ANGLE —(SPECIFY) Name &y,h0.lrA �. ocs'• rNG• <br /> DEPTH TO FIRST WATER�_ <br /> DEPTH FROM (R) BELOW SURFACE Mallin�g]Address T ' <br /> SURFACE DESCRIPTION r�allgs "�xuS � P <br /> Ft to Ft Desrnbe material, mn s7ze,color,etc CITY STATE ZIP <br /> WELL LOCATION <br /> ' ,• Address 1� SIsv eh7t Sj`rr+cT <br /> ' -1.5Rwlt C! SUVJ (� City 7bCkJbA <br /> County Sa vk .304 I v. <br /> ' 30 C c fi 4MrAC trte- APN Book Page Parcel <br />' M — Q fuj%ej 5dAj 1 5111011 Township Range Section <br /> �4r11 t Latitude I _NORTH Longitude Wi <br /> DEG MIN SEC DEG MIN SEC <br />' F3 ��� LOCATION SKETCH ACTIVITI (!rIt- rrix:A,M- fztrt[ NORTH /`NEW WELL <br /> ' PltlVil MODIFICATIONrREPAIR <br /> Deepan <br /> { I V CLAV. SOmc ,$ Itt - �—Other(SpeCll) <br /> 41(1Z t 1% (PM (f,a <br /> —OESiROr(Vasrnoe <br /> Procedures and Mete <br /> tib rntr- thi 5rC dE�d^e Under GEOLOGrCLI <br /> f 4 IL ndor ► Sl}C Pian �- PLAINNED USE( <br /> a (�) <br /> }� uj MONITORING <br /> 40 HI ' C l-h yt �/E ` �IL 1Y SR ve Q S WATER SUPPLY <br /> 7+o 3 c' I q s 160vc) — Darneehc <br /> Put,hc <br /> so SAW( ct-A*J, I/1[- ►v+rd,.,,I,t- _ Irngat,on <br /> ft4e JdAA mals def ,tj Indusinal <br /> TEST WELL <br /> CATHODIC PRO <br /> SOUTH TION <br /> 50 ; S ,.or : IAC Se(1 V _o1 illustrate or Describe Distance of 14 ell from Landmarks OTHER(Speuly <br /> a! {P { such as Roads Buildings Fences Rtorrs etc <br /> PLEASE BE ACCURATE & COMPLETE. <br /> hDRILLING -51 <br /> { <br /> METHOD '`0"f, _ rCM ayIrC FLUID <br /> WATER LEVEL h YIELD OF COMPLETED WELL -- <br /> DEPTH OF STATIC <br /> WATER LEVEL 30 (Ft) a DATE MEASURED <br /> ESTIMATED YIELD' (GPM) 6 TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL -5Q (Feet) 'May not be representan-a of a wells long-term yield <br /> DEPTH CASING($) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE GORE TYPE / FROM SURFACE TYPE <br /> HOLE <br /> DIA MATERIAL! INTERNAL GAUGE SLOT SIZE <br /> x ^d CE BEh <br /> DIAMETER OR WALL IF ANY FILTER PAC <br /> (trachea) K s GRADE MENT 70NITE FILL <br /> Ft to Ft 'm H _ onchss) THICKNESS Onchee) Ft to Ft (TYPE/SIZE <br /> (�) (r) (!) <br /> d ;a1�.r S IqO none .3 e/ <br /> a o.0�0 . '.21 r ✓ <br /> alis ��3.s nG>r(I I•re a <br /> I � <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> I the undersigned,certify that this report Is complete an accurate to he best of my knowledge dbell <br /> Geologic Loy Q C <br /> Well Construction Dusgrem NAME { �*�5011/j IRtfil JC1P�tL� �y1L <br /> (PERSON FIRM OR CORPORATION) <br /> PED OR PRINiTE ) r1 �AyL �L Q1,� n <br /> Geophymeel Log(n) (l.ft�11 y 4�� 1 W �,I k(t 4Q V 14 (� CA •Lf 5.4D I <br />' <br /> -,—,Other <br /> .. SoWI Wster Chemical Anelyass . <br /> 1,Oyher 10rAWN M412 T %ESS <br /> J CITY q/ STATE sr aIIbP <br /> RMA Iif )0STSognod 0 <br /> ATIAGH AD)TONAL NFC <br /> Q <br /> am SWXEO C-57 LICENSE NUM <br /> 41 <br /> DWR 188 REV 7 go IF ADDITIONAL SPACE IS NEEDED USE CONSECU ELY NUMBERED FORM <br />