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u%JAL)tiLINLil,Ait bi'AII-' U1 lALIPU1,i�l:� — _ •,. t 1L. <br /> For Lojal Repirements WELL COMPLETION REPORT <br /> Page Of Refer to Instruction Pampblet STATE WELL NO./STATION NO. <br /> s 11ElOwner's Well No. f!' No. 5 8�17 9 <br /> Date Work Began �� 2. �'� , Ended <br /> �6 A 5! 7� LATITUDE LONGITUDE <br /> Local Permit Agegch <br /> Permit No. Permit Date APN/TRS/OTH R <br /> 1( GEOLOGIC LOG WELL OWNER <br /> MLnr t) Ct ' WWAt*atr SY:�-*-F?iLI�S , l :Ic . <br /> .� ORIENTATION VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE �Jl nQ �$s y > <br /> DEPTH FROM 1.Vng fl <br /> SURFACE DESCRIPTION <br /> Ft. t0 Ft. ,D scribe material,grain size,color,etc, CITY -S STATE ZIP <br /> I- _ _ _WPI }' LpF�T.ATION <br /> Z50 Ct <br /> Sr Address <br /> City <br /> a County <br /> APN Book Page Parcel <br /> s or <br /> Township Range Section <br /> A.t2 ,2.10 or <br /> +C - 4 pd. Latitude DEG. I MIN. ' SEC. NORTH LongitudeDEG. I MIN. ' SEC. WEST <br /> 211 LOCATION SKETCH AACTIVITY (!) <br /> _ NORTH NEW WELL <br /> (.t- ;;2z_t If id <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Meterists <br /> Under"GEOLOGIC LOG") <br /> t PLANNED USE(S) <br /> w a 0! ) <br /> 3 to MONITORING <br /> iL WATER SUPPLY <br /> !l <br /> Domestic <br /> Public <br /> Irrigation <br /> Ind.elrial <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> r_ such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE& COMPLETE. <br /> DRILLING ROTW1 WA.TE f i <br /> METHOD FLUID <br /> .� WATER LEVEL, & YIELD OF COMPLETED WELL <br /> DEPTH OF STATI&"Il <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD r (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING ( C� � TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *A4ay not be representative of a well's long-terns yield. <br /> DEPTH <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE FROM SURFACE TYPE <br /> HOLE <br /> DIA. z o d MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) a W o� S GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> MENT TONITE FILL <br /> Ft. to Ft. m y �o LL (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> .rc <br /> 474 <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> .� I,the uny�yQrs Q)d,c tijy t ��t,is re o�rf{�s comj�I to and accurate to the best of my knowledge and belief. <br /> Geologic Log ,'7x G.�,_1... � D�.i�..l.-INd, TAC . <br /> Well Construction Diagram NAME <br /> - (P IRM, OR CQ�,PO TION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 11.1 r"{J.I_rf�'Y tt.- K�. i�r;���'er.�"� (:i: 'ft,'�t�-r <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY ZIP.-r <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER/AtITHORIZED REPRESENTATIVE DATE SIGNED C57 LICENSE NUMBER <br /> '� DWR 188 REV.7-90 1F ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />