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File with DWR WELL COMPLETION REPORT I I I I i t�__1�J <br /> Page-A—of ��AA M` `W' Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No - 1 No 5 2 5871 0 <br /> Date Work Began //�EEn,d''ed LATITUDE LONGITUDE <br /> Local Permit Agenc si1la I Fugue— H�LT" <br /> Permit No _O i.!2{p Permit Date i — <br /> � <br /> � �32Q APNITRSIOTHEB <br /> GEOLOGIC LOG WELL WELL OWNER <br /> ORIENTATION (.!!L) —VERTICAL _ HORIZONTAL — ANGLE _ (SPECIFY) Name s im1 `-` <br /> PAN <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address A 10 W CR <br /> Ds <br /> SURFTH ACE DESCRIPTION SRIJ 1RM C/A 94S 93 <br /> Ft to Ft Describe material,gran size color tic CITY WELL L CATION STATE ZIP <br /> ` Address r I_ _ <br /> City C <br /> To a A W u I ALL County I <br /> APN Book Page Pareel <br /> c� Or P Township Range Section <br /> or <br /> E ILL M3 Di Latitude - I I NOR Ti-I Longitude ' ' w£sT <br /> WELL— DEG MIN SEC DEG MIN SEC <br /> E, LOCATION SKETCH ACTIVITY (4)— <br /> NORTH <br /> '!)NORTH NEW WELL <br /> i <br /> LE r � A C��P MODIFICATION/DeepREPAIR <br /> r� _Deepen <br /> i � LhJ l <br /> PLAN —other(Specify) <br /> ' l <br /> i <br /> . DESTROY{Describe <br /> Procedures and Meto"als <br /> 1 <br /> Under GEOLOGICLOG ) <br /> Br I- PLANNED USE(S) <br /> Lu <br /> 1 �y W MONITORING <br /> L� <br /> , WAFER SUPPLY <br /> 1 L ,_ Domestic <br /> Public <br /> 1 �� IrntieGpn <br /> 1 <br /> Industrial <br /> TEST WELL <br /> 1 CATHODIC PROTEC <br /> SOUTH TION <br /> ' Illustrate or Describe Distance of Well from Landmarks ,.... OTHER(Specify) <br /> S RCR such as Roads LT ~ PLEASE BE ACCUBuildiRATEeB¢s Rivers etc COMPLETE <br /> DRILLING <br /> ' METHOD FLUID <br /> WATER LEVEL 3 YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) S DATE MEASURED <br /> ' ESTIMATED YIELD' (GPM) d TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet} TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEP'T'H OF COMPLETED WELL (Feet) •May not be representative of a wells long-term yield <br /> DEPS CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE <br /> HOLE — TYPE <br /> INTERNAL, GAUGE SLOT SIZE <br /> DIA z a w MATERIAL! CE BEN FILTER PACK <br /> z ,,, x� a DIAMETER OR WALL IF ANY <br /> (Inches) o�, J GRADE MENT TONITE FILL <br /> Ft to Ft s o _ (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> Ir <br /> 1 , <br /> 1 <br /> ATTACHMENTS (tf) CERTIFICATION STATEMENT <br /> Geologic LopI, Rn R <br /> the undersigned cerldy that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME W �W l i-!/ Pl L) U 0-0 ,, <br /> (PERSON FIRM OR CORPORATION)(TYPED OR PRINTED) <br /> SOO/Geophyter LermaLog(s1 s O p Box 33 Rio , ■ srA CA <br /> _ Other tsA a nah e� V CITY STATE ZIP <br /> 1{ 111Y ¢ ADDRESS <br /> Athtr_ �O O <br /> ATTACH ADDITIONA.L VIFORMAT ION fF IT EXim Slpnad <br /> WELL DRILLER AUT RIZEO EPRESE TI DATE SIGN G 5J LICENSE NUMBE <br /> DWR 188 REV 7 90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY F'­URr_F&n FORM <br />