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page Of Refer ao Jnsrrnrr+aa Pamphlet + V j STATE wELI NO rSTATION NO <br /> pwner'S Well No 6 ^ No <br /> Date Work Began ,rude 532977 LATITUDE <br /> Local Permit Agency 70av i LONGITUDE <br /> Permit No. �•Z- Permit Date APN+ <br /> IC£OLOGIC LOC WE{ \ER <br /> ORIENTATION (!} VERTICAL _ HORIZONTAL , ANGLE —_(SPEC" Name 4..D. a►hr- e-z_ <br /> DEPTH TO FIRST u kTEA (FL) BELOW SLRFACE Aladin -kd4rgs 4!!L. 1>y <br /> DEPTH FROM ` / C <br /> SURFACE DESCRIPTION � !rGr) 7 d <br /> Ft to Ft Dettnbe mxe wl gram rice color etc STATE ZIP <br /> WEL LOCATION <br /> Address <br /> Pc <br /> fsAs <br /> f f <br /> County gra <br /> APN Book Page Parcel <br /> Township Range aLC-' Section <br /> LatitudeNORTIi Longitude UDE <br /> DEG MIN SEC DEG MiN SEC <br /> LOCATION STRETCH ACLVITZ {!) <br /> NORTH <br /> —Le—NEW WELL <br /> MODIFICATION,REPAIR <br /> Deepen <br /> i <br /> Other(Speefty <br /> r <br /> I {l` DESTROY(Desenoe <br /> ' K J andMajor <br /> Undw GE ICLO <br /> r fi PLANNED USES <br /> 07 <br /> + f W <br /> ' '} � � MONITORING <br /> WATER SUPPLY <br /> — Domestic <br /> f <br /> ' — Public <br /> f — Irrigation <br /> — industrial <br /> ' + — TEST WELL <br /> ' _.� CATHODIC PROTEi <br /> + f SOUTH TION <br /> 111110r4re or Describe Distance o/well/rem Landmarks _ OTHER(Spoefty) <br /> ' <br /> such as Roads Buildings Fences Rtaen etc <br /> + f <br /> PLEASE BE ACCURATE & COMPLETE <br /> i <br /> ILLING <br /> METHOD f�t9la! rA� <br /> FLUID /` �-11! <br /> ' WATER LEVEL & YIELD OF COMPLETED WELL <br /> ' DEPTH OF STATIC ���p + <br /> f WATER LEVEL---f 11�_(Ft) & DATE MEASURED a <br /> ESTIMATED YIELD' (GPM) 3 TEST TYPE <br /> TOTAL DEPTH OF BORING 17 (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL - 7 (Feet) May not be representative of well i long-rerm)arid <br /> DEPTH CASING(S) ANNULAR MATERIAL <br /> FROM SURFACE BORE DEPTH <br /> HOLE TYPE FROM SURFACE TYPE <br /> DIA ,c W a MATERIAL r INTERNAL GAUGE SLOT SIZE <br /> z� DIAMETER OR WALL IF ANY CE BEN <br /> F( to Ft (Inches) W GRADE (Inches) THICKNESS MENT TONITE FILL FILTER PACK <br /> `¢,3 _ Dncnesl Ft to Ft (TYPEtSIZE) <br /> 1 F 2 yI7 o.a <br /> f <br /> fAT ACHMENTS (!) ' <br /> CERTIFICATION STATEMENT <br /> logic Log I,the undersigned,certify that this report is complete and accurate to the beat of my knowledge and belle( <br /> Wall Construclion Diagram NAME I/L <br /> Geophysical Log(s) ( W ' Mil. DR CDWoRAT10N) (TYPED OR ED) <br /> SollrWotor Chomreal Analyaoa r •O0 p �ts� C'4 /s <br /> nl <br /> 0 — Other ADDRESS CITY A C. STATE ZIP <br /> -7/-OCY79 <br /> ATTACHAOOtriOlYAL rNFORA(ATtON 1F IT TeR7ST5 SipnBd HpR�p REPRESENTATIVE q_G/ <br /> DATE SIGNED <br /> DK C 57 LICENSE NUMBER <br /> It It)a REV 7 So IF ADDITIONAL SPACE IS NE ED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />