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ORIGINAL STATE OF (ALiI ORNIAW v — N T Fl I <br /> File with DWR WELL COMPLETION REPORT 0 2 S a S G 1 M <br /> Page / of Refer to lnsrruciron Pamphlet STATE WELL NO iSTATION NO <br /> Owner's Well No '3 _ No533333 ❑ <br /> Date Work Began Ended __Y_-_2V_;-97' LATITUDE LONGITUDE <br /> Local Permit Agenev��W �(p2BtU_;D aafm% <br /> Permit No Permit Dat( PHI <br /> LOGIC LOG *A ELL 0%NER <br /> ORIENTATION (.!L — HORIZONTAL _ ANGLE (SPECIFY) Name eA0"Pd✓ elA667-3 9!:�& -- <br /> DEPTH FROM DEPTH TO FIRST NATER (Ft) BELOK SURFACE Mailing Address <br /> SURFACE DESCRIPTION . TAW .PA6 jfAJ` 3,YM <br /> Ft to F! Describe material grmn nzc,color err CITY STATE ZIP <br /> WELL LOCATION <br /> Address "99 �+G �✓-' <br /> , <br /> L co, . :27eK✓ <br /> % County <br /> A PNI BOOK Page Parcel <br /> or <br /> Township Range Section <br /> A.+s.Qor <br /> LahtTtde I NORTH Longitude WEST <br /> i DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY ;�) <br /> NORTH NEW WELL <br /> MODIFICATION I REPAIR <br /> i <br /> �J _Deepen <br /> /? <br /> w — Other(Speedy) <br /> _2:n DESTROY(Deacribe <br /> Procedures and Marennis <br /> ' f Under GEOLOGICLOG) <br /> PLANNED USE(S) <br /> w U) (�) <br /> MONITORING <br /> y{ WATER SUPPLY <br /> Domestic <br /> — Public <br /> _ Irnpation <br /> , <br /> Industrial <br /> s , <br /> TEST WELL <br /> /// — CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Dombe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads lusldtngs Fences Rivers etc <br /> PLEASE BE ACCURATE Lr COMPLETE <br /> DRILLING <br /> ' METHOD FLUID <br /> 11 ATER 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) "Mav not be representative of a wells long-term yield <br /> DEPTH CA 51NG(S) ANNULAR MATERIAL <br /> FROM SURFACE BORE DEPTHHOLE TYPE(.!L) FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA = x I;to MATERIAL/ DIAMETER OR WALL IF ANY CE BEN <br /> Ft to Ft (Inches) J U o J GRADE (Inches) THICKNESS (inches) Ft to F[ MENT TONITE FILL FILTER PACK <br /> m (�) (�) (✓ ) (TYPEISIZE) <br /> i <br /> , <br /> ATTACHMFNTS (!) CFRTIFICATION STATF MFNT <br /> Geologic Log i the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> APWell Construction Diagram NAME W `at � , <br /> Geophysical Log(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> _ <br /> Soil/Water Chemical Analyses 14 .6T `V <br /> Other DRESS CITY t� .lSTATE ZIP <br /> ATTACH ADDITIONAL INFORMATyON IF IT EXISTS Signed ' 7y�� yfI <br /> GRILLER AUTHO D REPRESENTATIVE DATE SIGNED C51 LICENSE NUMBER <br /> oWR INR RE v 7 u0 IF ADDITIONAL SPAC IS NEEDED USE NEXT CONSECUTIVELY NUMB ED/�F�{ M <br />