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ORIGINAL <br /> sr E or C1LIF(�ii11> DWR USE ONLY _ Do NOT FILL IN <br /> Fide with DWR <br /> 'WELL COMPLETION REPORT <br /> R <br /> t efer to 1tITtmctfc,A nj <br /> Pr, pl,fet STATE WELL NOISTATION NO <br /> Page of T <br /> "v <br /> Orler s Well No '' f "f �No 1078861 <br /> I]atE3 N%Ork Began Ended r�� T vrfr LATITUDE LONGITUDE <br /> Local Permit Aaencv 15 t- r1y _ <br /> Permit No - 4 lIl y` }^ -r -� Z� APNlTRSIOTHER <br /> Permit Date_�,r <br /> GEOLOGIC LOG J1 ELL O«NFR <br /> ORIENTATION (✓} VERTICAL <br /> DRILLING 'moi _HORIZONTAL —ANGLE (SPECIFY) Name + ( � L� i ( ✓� <br /> � <br /> DEPTH FROM METHOD '� FLUID _ Nfadinr lddress—Pili f!. 4 i % Y <br /> SURFACE DESCRIPCip� <br /> Ft to Fl Describe 1rIaterirll ,raut Sr,e color etc CITY STATE ZIP <br /> �� ►�Fl <br /> lddress t_ t �OC TTIA�--*—s-j( <br /> County - <br /> ' APN Book Page 'Parcel <br /> Toxn�hr A<tnbe Secttorr, <br /> Lat � <br /> L t:_) _N Lon r ; <br /> I ' r '�M14 SEC � DEG MIN SEC <br /> � n 1—' <br /> LOCATION SKETCH ACTIVITI f } <br /> NORTH -JA NEW WELL <br /> tA/,DfFICATIONIREPAIR <br /> Deepen <br /> 1 1 — Other(Specd <br /> I I f <br /> DESTROY{Descrrbr <br /> Procedures and Mare <br /> I y Under GEOLOGIC! <br /> USES ( ) <br /> 1 r' WATER SUPPLY <br /> Domestic _.._ Puh! <br /> I r � t- � Irngahon � Irdu <br /> u 'J en <br /> MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> I , <br /> HEAT EXCHANGE <br /> ' I DIRECT PUSH <br /> I INJECTION <br /> 1 i <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH <br /> 11hWrate or Desmbe Distouce of d ell front Road, Budd4ags REMEDIATION <br /> ponces ReUers etc and nitach a nla, L15c addrrl-rtal ver-er OTHER(SPECIFY) <br /> necessary PLERSE BF ACCL'PA E 2- COUPLET <br /> WATER LEI EL & I IELD OF COMPLETED t1 ELL <br /> ' DEPTH TO FIRST WATER _ (FI] BELOW SURFACE <br /> ' I DEPTH OF STATIC f / <br /> WATER LEVEL f (Ft)&DATE MEASURED <br /> ESTIMATED YFELD {GPM} & TEST TYPE <br /> TOTaL DEPTH OF BORING l��..., TEST LENGTH <br /> {Firs) TOTAL DRAWDOWN (FI) <br /> TOTAL DEPr H OF COMPLETED WELL _.f_�_(Feet) 'May not be representatrz,e ora welps long-term yreld <br /> DEPTHBORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE <br /> TYPE <br /> DfAx w ¢o a MATERIAL f INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft (Inches} ¢ e a GRADE DIAMETER OR WALL IF ANY MENT TOIVJTE FILL FILTER PACF <br /> m _ (Inches} THICKNESS (inches} F[ to Ft (TYPE/SIZE) <br /> Lt i <br /> I <br /> I t <br /> ATTACHMENTS CERTIFICATION STATEDIENT <br /> Geologic Log I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME <br /> 4 <br /> Geophysical Log(s) (PERSON FIRM OR CDRPOR TIO 1 (TY OR PRINTED) <br /> —_. SodNJater Chemical Analyses �- r T sf ` - t r•,-�• ( _ ` ,Y� r j <br /> - Other ' ! I ADDRESS , <br /> CITY STATE 2iP <br /> ATTACH AOD)TlONAL INFORMATION tF J7 EXISTS Srgnetl �� - _ •r-- f AL1 - _� <br /> C 57"LTENSED WATER WELL <br /> CONTRACTOR—DATE SIGNED G 57 LICENSE PIUMREf <br /> DNI R ISS iiEl W;D, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSI-CUTIVELY NUMBERED FORM -- OSP 03 <br />