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ORIGINAL. STATE Or (ALIT UHNIA WA N Y — T F I <br /> File with DWR WELL COMPLETION REPORT D X s <br /> Page Of Refer to Instruction Pamphlet STATE WELL NO ISTATION NO <br /> Owners Well No _AAI —� No 533327 <br /> Date Wort. Began y',?Z'f 7 Ended 77__ __ LATITUDE LONGITUDE <br /> Local Permit AgencYl.�✓��,mr—Al �Rer <br /> Permit No Permit Date PNt t <br /> OLOCIC LOC WELL ON NER <br /> ORIENTATION [�) VERTICAL _ HORIZONTAL - ANGLE - (SPECIFY) Name <br /> ehy <br /> DEPTH FRDEPTH TO FIRST WATER (Ft) BEL01A SURFACE, Mailing Address a <br /> pM <br /> SURFACE DESCRIPTION ftMcl <br /> Ft to Ft Describe material Rratn size talar,err CITY STATE ZIP <br /> WELL LOCATION <br /> Address /O <br /> County . �L04AOOP 1749 ✓ <br /> Vie <br /> Sod API\' Boot. Page Parcel <br /> 100, Township Range Section <br /> or <br /> Latitude NORTH Longitude i i WEST <br /> _ DEG MIN SEC OEG MIN SEG <br /> LOCATION SKEI CH ACTIVITY {�} <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> i <br /> Deepen <br /> oA _Other(Specify) <br /> _ DESTROY(Descnbe <br /> . Procedures and Matensts <br /> Under GEOLOGICLOG) <br /> PLANNED USE(S) <br /> t� MONITORING <br /> WATER SUPPLY <br /> f 0 Domestic <br /> it <br /> A <br /> \_ Public <br /> cIrrigation <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Desenbe Distance of`T'ell from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE di COMPLETE <br /> DRILLING ^'* <br /> METHOD FLUID <br /> WATER LEVEL d 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 (I eet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representarime of a well's long-teen yield <br /> DEPTH <br /> CASINC(S) DEPTH ANNULAR MATERIAL FROM SURFACE BORE <br /> HOLETYPE ✓ <br /> DIA FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE CE BENc W MATERIAL/ <br /> (Inches) �+ o� J GRADE DIAMETER OR WALL IF ANY ME NT T(}>VITE FILL FILTER PACK <br /> Ft to Ft v (Inches) THICKNESS (orches) Ft to Ft (TYPE/SIZE) <br /> r <br /> ATTACHMENTS (L) CERTIFICATION STATEMI NT <br /> — Geologic Lop I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAM r' <br /> Geophysical Log(a) <br /> (PERSON FIRM OR CORPORATION) (TYPED DR PRINTED) IF <br /> &&AWS 7�/ <br /> Soil!Water Chemical Analyses � � 4 <br /> ADDRESS CITY STATE ZIP <br /> — Other i <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> L DRILLER AUTHO D REPRESENT.TIVf D0.T[ SIGNED C 57 LICENSENUMBER <br /> DWS 188RLV 7 90 IF ADDITIONAL SPAC ES NEEDED IJ E NEXT CON� Cr�IVEIy NUM9ERED,FO%M` <br />