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Of Refer tolnstruerron Pamphlet ^" <br /> page �,7` �. No 5329?9 <br /> pwner's Nell No � � � , ended "1 �� LATITUDE LONGITUDE <br /> Date Work Began <br /> Local Permit Agencv r ev/AI 1 _ I I I I I I I I <br /> I Permit No Da Permit Date 1-23--09 , <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (2!1) 1L VERTICAL _ HORl20NTAL — ANGLE —(SPECFn Name mah"W an CA 67— <br /> DEPTH TO FIRST W.TER (FL) BELOW SL RF4CE riaihn A r IS23 <br /> DPHFROM DESCRIPTION CIE - 19- <br /> SURFACE TY 9S'Z C <br /> STATE 7JP <br /> Ft to Ft Descnbe mas"I gram size,color etc WELL LOCATION <br /> Address <br /> T�4 4,0 &eAa(e Leloy City �a n <br /> County a, - <br /> NPN Book Page Parcel <br /> Township L—Range aAV---Section — <br /> w <br /> Latitude + NORTH Longitude <br /> � OEG MIN SEC DEG MIH SEG <br /> LOCATION SKETCHACSIVITI {! <br /> + , NORTH — NEW WELL <br /> uOOIFICATION/REPAIR <br /> ` Z- ,. Deepen <br /> i Other(Specs <br /> + <br /> —DESTROY(Dsa <br /> Procedures end Mol <br /> }. Wider"GEOLOGICI <br /> /J l.4 5 >- PLkXNED USE <br /> LU <br /> m td �(�} <br /> —L U NRORING <br /> WATER SUPPLY <br /> ' Domeauc <br /> yJ1{u� — Pub6c <br /> + •[r'11 <br /> knpauon <br /> J <br /> Induatnd <br /> TEST WELL <br /> CATHODIC PRS <br /> SOUTH TION <br /> lHustrate or DvstriLe Dtatance of We from Landmarks ._ OTHER(Specir <br /> + such as Roads Building Fences Rivers etc <br /> PLEASE BE ACCURATE 6 COMPLETE. <br /> + <br /> DRILLING �} q <br /> METHOD `�4 FLUID /t/Ste -- <br /> WATER LEVEL & YI LD OF COMPLETED WELL — <br /> DEPTH OF STATIC „p <br /> WATER LEVEL �' (Ft) S DATE MEASURED <br /> ,GG ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet))p TEST LENGTH (Hre) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feel) °May not be represenwisve of a well's long-term yield <br /> DEPTH <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> BORE TYPE FROM SURFACE TYPE <br /> FROM SURFACE <br /> HOLE ✓ <br /> DIA ,� z d MATERIAL/ INTERVAL GAUGE SLOT SIZE CE FAKN <br /> N <br /> pnchea) it c` s GRADE DIAMETER OR WALL. IF ANY FILTER PA( <br /> (Inches) THICKNESS pnchaa) Ft to Ft MENTETEFILL (TYPErSIZI <br /> Pi to Ft <br /> cr 13 rI Fe- 2- <br /> 13 W <br /> vsJa <br /> + <br /> AT ACHMENTS (!) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report Is complete and accurate to the best of my knowledge and bel <br /> ructan Diagram NAME <br /> Rw4>"wd &,-NAI <br /> Wmto (PESDN <br /> FptM. DR CDrtPDRAnDH) (TYPED OR Pa ) <br /> Geophysical Lop(a) P.O. 8,,,w CA 9fFS7� <br /> SoBIWator Chemical Anatyaco ADDRESS CITY STATE .g 2iP <br /> Other <br /> ATTACH ADDrFXWAL kWORMATION IF IT EXISTS Signed <br /> MOR'�'fl1ECI�R REPRESENTATIVE DATE SIGItrO C 57 ttCErISE tRIN <br /> 1)NIt198REV T90 IF ADDJTIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />