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\rNLY D NOT FILL I— <br /> QUADRUPLICATE STATE OF CALIFORNIA D W R USE O <br /> �. For Local Requirements WELL COMPLETION REPORT <br /> Page ' Of__L Refer to lnTiruction Pampblet STATE WELL NO/STATION NO <br /> Owner's Well—N oo� MW_ /11/q 525N $71 11 111 :E111 [ iElDate Work Began Ende n LATITUDE LONGITUDE <br /> 4 <br /> ,Local Permit k enc � �/� CO Ll I6L; EALT <br /> Permit No Permit Date APNrt <br /> OTHER <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (✓) — VERTICAL HORIZONTAL — ANGLE — (SPECIFY) Name To J C KIFT I <br /> DEPTH FROM <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Wa ng,Ad ess <br /> t'I <br /> SURFACE DESCRIPTION `DN <br /> Ft to Ft Describe material,grain size,color,etc CITY /' STATE ZIP <br /> E t-;- A It -I Address %k <br /> City <br /> �i),I_ UCK70N <br /> MONITO M "e I.- ILL M.WCounty 5 Fj T 0 <br /> APN Book Page Parcel <br /> I ! Township Range`' <br /> or <br /> ` Latitude DEG I MIN I SEC NORTH Longitude DEG I MIN I SEC WEST <br /> LOCATION SKETCH ACTIVITY (Z.)— <br /> ' t NORTH — NEW WELL <br /> } <br /> 4 O l <br /> E E F- T i h C }-k F_ MODIFICATION PAIR <br /> Deepen <br /> : 10 SUREFICE W ; TR <br /> 1 7- —Other(Specify) <br /> NENE <br /> 4 1= 1 } <br /> X DESTROY(Describe <br /> Procedures and Materials <br /> ' Under GEOLOGIC LOG) <br /> I� y PLANNED USE(S) <br /> ui Q 0L) <br /> ) <br /> Lu MONITORING <br /> 1 ,tFTM= AN F WATER SUPPLY <br /> i <br /> Domestic <br /> 1� <br /> — <br /> Public <br /> � Irngalion <br /> 1 4 ��- _- Industrial <br /> i <br /> i TEST WELL <br /> t <br /> — CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> p such as Roads Buildings Fences Reoers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> e <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMArEb YIELD` (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) 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 CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE I TYPE — FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE: <br /> DIA x MATERIAL! CE BEN <br /> (Inches) w =� a DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to F( <br /> o= J GRADE (inches) THICKNESS (Inches) Ft to Ft MENT TONITE FILL (TYPEISIZE) <br /> I <br /> i <br /> ATTACHMENTS (L) CERTIFICATION STATEMENT <br /> Geologic Log I, the undersigned certify t h reporLis mtpleie n�a�curate lot e best of my knowledge and belief <br /> 4r11j�"/��Ve�(1T.►t IV7 I L Il. 6^ �t►S <br /> Well Construction Diagram NAME <br /> ERSON FIRM OR CO♦RRPPORATION (TYPEDORPRINTED) f� /.�� C +j+�� 1 <br /> GeI/WacalLog(sI 6o s./ Ff 10 \1 157A ti+ A 94-5 1 <br /> 1 ! i l,} <br /> Sai]!Wa Chemic t naly ADDRESS <br /> Other j /CITY STATE <br /> � � f <br /> ATTACH ADDITIONAL INFORMATION IF 1T EXISTS Signed K. <br /> WELL DRILLER AUTHORIZED REPRESENTATIVE DA7E SIGNED C 57 LICENSE NUMBER <br /> DwR 188 REV 7so IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />