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UtINUINAL <br /> Ile w th OWR siAi>; Of- c,Auruttivin <br /> WELL COMPLETION REPORT <br /> Tage of i— Refer to Inrrruefion Pamphlet STATE WELL NO ISTAT. NO I <br /> Owner's Well No —rj 6 _ No J <br /> Date Work Began end J617A, LATITUDE LONGITUDE <br /> Local Permit Agenc l'a <br /> Permit No ` 'i AN) Permt Date — <br /> GEOLOGIC LOC " WEL OWNER <br /> ORIENTATION (z� VERTICAL —HPTRHFROM OMZZO�NTTAL —ANGLE —(SPECIFY) Name 1 <br /> DEPTH TO FIRST WATERII (FL) BELOW SURFACE iling Address , <br /> DstA( DESCRI TION <br /> Ft to Ft i7u be 1, am u,color,ere CITY f �� ( t W E L OCA N s ATE P <br /> ' Addrts` <br /> City <br /> County <br /> ' APN Book Page Parcel <br /> ' To nship—Range Section � <br /> t Latitude I NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> i < LOCATION SKETCH _ ACTIVITY <br /> NORTH `Z.ptEw <br /> WELL <br /> ✓ ` ~'�`5� ` ,� �' j MODtFICAPONIREPAIR <br /> r ' ,. ". \ 1•`'� `E �.Deepen <br /> r , • t <br /> t —other(Specify) <br /> _DESTROY(Deacrtha <br /> i r r`3 �" Procedures and Matenata <br /> Undw-GEOLOGIC LOG) <br /> PLANNED USE(S) <br /> uj <br /> \ s� 0 MONITORING <br /> WATER SUPPLY <br /> , <br /> Damest,c <br /> Public <br /> , r <br /> _ Irnpa4on <br /> Mduatnel <br /> TEST WELL <br /> SOUTH <br /> _ CATHODIC PROTEC <br /> TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Speafy) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE& COMPLETE <br /> DRILLING <br /> ' METHOD FLUID / <br /> , e <br /> WATER LEVEL 6 YIELD OF COMPLET •D WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL � (Ft) S DATE MEASURED r <br /> ESTIMATED YIELD• i trr77— (GPM) S TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Nis) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL > (Feet) 'May not be representative of a uw1l's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE : FROM SURFACE TYPE <br /> — <br /> DIA ,� z a- MATERIAL! INTERNAL GAUGE SLOT SIZE <br /> (Inches) z W s DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> Ft to Ft GRADE (mss) THICKNESS (taches) Ft to Ft MENT TONITE FILL <br /> m { ] (�) (TYPE/SIZE) <br /> 7 , , <br /> � Q , <br /> 7 <br /> ATTACHMENTS (t) CERTIFICATION STATEMENT <br /> Geologtc Lop I the underst ped certify that this report Is comp to d curate to the best of my knowledge and belief <br /> 0�, <br /> Well Construction Diagram NAME <br /> (PERSON FIRM OR CDR IDN) (TYPED OR PRINTED) <br /> Geophysical Lops) ( � / <br /> Soil/Water Q emvc Analyses tf</J, <br /> Other ADDR 5 T,E/ IP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS SIQae r <br /> E AUTH RED REPRESENTATIVE DATE SIGNED C57 tICENSf NUM EA <br /> DWR188Ri-V790 IF ADDITIONAL SPACEVYsIEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />