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UU AL)hUi'L14 A i L SIAII: OF 1 UALIl'OhNIa — I L — <br /> For Loyal Repirements WELL COMPLETION REPORT' 1 1 J I I I I 1 I I <br /> a � <br /> Page of Refer ro Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. �01nu 12 <br /> 5 r'S/95 <br /> No. 580179 <br /> Date Work Began � , Ended <br /> �� ; ! 7 LATITUDE LONGITUDE <br /> Local Permit A&T..y <br /> Permit No. y Permit Date APN/TRS/OTHER <br /> X GEOLOGIC LOG WELL OWNER <br /> MUG-Talan 's W;.,Atftr `��r•T-(r?� . Inc <br /> i ORIENTATION (t ) _VERTICAL —HORIZONTAL _ ANGLE _(SPECIFY) Name <br /> ,p ..a m. .. 1 t .) '( <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE N;e�ngffl:�� ,s <br /> DEPTH FROM l G {.�rt <br /> SURFACE DESCRIPTION <br /> Ft. to FtWt�it:Z}'. ,Describe material,grain size,Color,etc. CITY Lt�1[• Lp��ATION STATE ZIP <br /> Pr_ a — .. ,,. . <br /> Address <br /> City <br /> c c1l.I i t( <br /> a .r 41 County <br /> APN Book Page Parcel <br /> Z;.c S or <br /> < Township Range Section <br /> Latitude I 1 NORTH Longitude I I WEST <br /> w. - ..- *4,: DEG. MIN. SEC. DEG. MIN. SEC. <br /> -.a LOCATION SKETCH ACTIVITY (!)l <br /> NORTH NEW WELL <br /> !,... .c, <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> _DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> PLANNED USE(S) <br /> w a 0L) <br /> W MONITORING <br /> WATER SUPPLY <br /> 1l <br /> Domestic <br /> Public <br /> Irrigation <br /> Industrial <br /> ..TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> .... i Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE& COMPLETE. <br /> DRILLING d-Z6.ITAf`y WATEJ� <br /> ._ <br /> METHOD FLUID <br /> WATER ,LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STAT16'"' <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING �Fe�r � TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representative of a well's long-term yield. <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE <br /> zo! MATERIAL/ FROM SURFACE TYPE <br /> DIA.HOLE — INTERNAL GAUGE SLOT SIZE <br /> CE- BEN- <br /> (Inches) Z a Z d GRADE DIAMETER OR WALL IF ANY FILL FILTER PACK <br /> ou MENT TONITE <br /> Ft. to Ft. m H (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE SIZE) <br /> PVT <br /> a. <br /> 1192 .045 200 c <br /> ATTACHMENTS (•') CERTIFICATION STATEMENT <br /> I,the un d,1d,c�rti,(y thKaa+,t�his reDo�rtils com�7I to and accurate to the best of my knowledge and belief. <br /> Geologic Log 91or_L.i ti tJi[. L L i Nd, 7NC . <br /> Well Construction Diagram NAME <br /> (PE SO('� FIRM, OR Cog TION) (TYPED OR PRINTED) �d <br /> Geophysical Log(s) 1 .19 rX 3.bf''-`r r.- t> i r:L1L"�i t.!"s C A. 5._n 117 <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITYr ,r RSTATE ZIP.- <br /> Other )...• fif:rf3f:-,tr <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed ` <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> '� DWR 188 REV,7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />