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ORIGINAL 1,TATP 01 ( Al 11011NIA to &_R N Y — N T FIL I <br /> File with DWR WELL COMPLETION REPORT STATE WELL NO ISTATlOk NO <br /> Pagel._,. Of Refcr to lnsirucrion Parnpblet ❑ <br /> Owner s Well No ?>"1W' No 5 .� i v 2 J <br /> Date Work Began .27.S7 Ended *21:17 LATITUDE LONGITUDE <br /> • Local Permit Agents ^' <br /> P / R <br /> Permit No Permit Date <br /> �EOLOGIC LOG %ELL OWNER <br /> ORIENTATION (!) _ VERTICAL — HORIZONTAL _ ANGLE — (SPECIFY) Dame 040 <br /> DEPTH TO FIRST WATER (Ft) BELOW SURF4(L Mulling Address ? <br /> DEPTH FROM 9r <br /> SURFACE DESCRIPTION <br /> Ft to Ft Desenbe ruaterral grain size color ate CITY WELL LOCATION STATE ZIP <br /> Address. � 1 <br /> City <br /> CountsJeer <br /> ^T <br /> APIA' Book Page Parcel <br /> To unship Range Section <br /> LatitudeNORTH Longitude _ WEST <br /> DEG MIN SEC DEG MtN SEC <br /> LOCATION SKETCH ACTIVITI (�) <br /> +p,ye NORTH ,.,_. NEW WELL <br /> Mw+ MODIFICATION/REPAIR <br /> _Deepen <br /> i <br /> —Other(Specify) <br /> r <br /> DESTROY(Describe <br /> r Procedures and Matertala <br /> Under GEOLOGICLOG) <br /> I- PLANNED USE(S)- <br /> 0L) <br /> W MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> ' Public <br /> , <br /> Irrigation <br /> i <br /> industrial <br /> 74,A- <br /> 4_ TEST WELL <br /> ' ._,.... CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from LandrrrarKs OTHER(Specify) <br /> such as Roads Buildings Fences Ricers etc <br /> PLEASE HE ACCURATE & COMPLETE <br /> DRILLING <br /> METHOD FLUID <br /> WATER 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 80RING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) ' May not be representative of a wells long-Term weld <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE r FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA z a MATERIAL! CE BEN <br /> (Inches) GRADE <br /> a w a� d DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> o u J <br /> Ft to Ft (Intoes) THICKNESS (Inches) Ft to Ft � (�— � (TYPE/SIZE) <br /> ) f—I <br /> r <br /> r <br /> r <br /> ATTACHMENTS (•!) CERTIFICATION STATEMENT <br /> Geologic Log i the undersigned certify that this report is complete and accurate to the best of my knowledge and behet <br /> — Well Construction Diagram NAME <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTE()) If <br /> — Geophysical Log(s) <br /> _._,_ SoiU Water Chemrpal Analyses <br /> 0,040 411t� 00- 25M <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Srpnad <br /> L DR11LERIALITHOJUE0 REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> DWR IM RLV 7 90 IF ADDITIONAL SPAC IS NETFDED USE NEXT CONSECUTIVELY NUMBEREChfORM <br /> C• <br />