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Owner's Copy _ F1.1, COMPLEI_JN HEPOkCi - L ' ! IL. I I I 11J I <br /> Refer to lnstructiurt Pamphlet STATE WELL NOJSTATION NO. <br /> Page�_of_+ _ "o. Q 7 15 rr--------�� <br /> Owner's Well No. - t t 1�._ __ r I <br /> r f LATITUDE LONGITUDE <br /> Date Work Megan; s ' It Eutlud /� ;�5 �'1 <br /> Local Pennft Agency A r /' '%`h 1-�`�;. i tai' L�L�L I I I I I I -�__ <br /> K Y �� .:1 — Cr c_ b..fl-1 j�t crL ArNn•AsroTtiEP <br /> Permit No. � _'.._(F 2: . .-Permit Date 4!7--!!2 3� <br /> GEOLOGIC LOG `a' ELL OWNER <br /> ORIENTATION (!1 —'/EMIi•GAL ,—_HORIZONTAL •.--ANGLE __OPECIFY) Name r=^"' 1"' '7"`!t�\ ✓• '•G--`''�`��+—�1•„�, ,yn "'a L'^S"t`'ii^" <br /> DRILLING <br /> '- METHOD LIA-'t ( ± +'. :'fsi FL1J10 t r Nai)lI) 1AIJ <br /> DEPTH <br /> C�3'CSS*•.� ' G <br /> ARO <br /> M.. DESCRIPTION --�� �Z�'.. <br /> SURF <br /> F1. to Ft. Duyuribe material, grain Hze, color, a.tc_• ;L„/�� �a 4a-=,, ., <br /> k WELL LOCAIIOA <br /> --•r-----r------ — �.. 5 •Ac�drl'�;'�'�.�f-+t^` "�-���•f�:�i.��I <br /> f v <br /> I I ,. - .� •.>y. .��011ri`�"�`L�c•�i--- '��t `T�T—i " .: .. <br /> •�11 ��I_,•`�iS.->c1+•✓'L �='t�->1r�.,.:: �:�,.��` _ilii Book3 Pale.�... _Parcel�"�:�_ __ <br /> i I --. _ � � utiy➢i,Slii I3aa e'. Section <br /> I I fr�E '��—!• .j `�" I.7dC• .D..z <br /> W <br /> \�* �J_ a.. •_N <br /> G MIN, SJEQ� <br /> l.C1CAT[CIN.SKETCH A�UIVITY ; ) <br /> NORTH <br /> L"W VVELL <br /> MODIF! ATI ONIREPAIR <br /> -- ti.. - t j _ DESTROY(09scribe, <br /> k- <br /> _....... <br /> t' E? _!1\�..,..- ^'"•t ;.._ _. ...__ GEOGIC <br /> Or <br /> Under. LOG' <br /> USES( ') <br /> WATER SUPP.�- <br /> ,t1 `�C MOWTGPIN(G-IfL, <br /> iI TFS-r wr-L— <br /> t <br /> AO <br /> �A'ri.�GIG/'N')itG71i1N <br /> DIRECT PU,rt-- <br /> c; '`' I ✓ <br /> IruEcrrma__..._ <br /> I I •VAParl EXTRn,:,TIGN <br /> SOUTH--- <br /> _ Ir_Mtu Anvra---- <br /> 14ustratz br Describe Distanm c%41 front Roads,&WdiTv <br /> i I 'Femw,Rum,ek.'mrd cttea3 a two.Use <br /> ---T — '. 07HER(SPECrFYI <br /> ;C CO3PLETst <br /> ner•-vary.PLEASEBE ACCURATE <br /> --- <br /> _ <br /> ---r----r IVATER LEVEL &.YI.LrLD,OF COt PL;EHE; 1VELL` — <br /> "�'— DEPTH T.0 FIRST.WATER._--(Ft.)BELOW SURFACE. <br /> DEPTH OF STATTG :...'. <br /> WATER LEVEL (FI.)&DATE MEASURED <br /> I ESTIMATED YIELD'-- (GPM) &TEST TYPF�__:T:' <br /> T(yrAL DEPTH OF BORING' __ tl^eec'..<.:;:. <br /> TEST LENGTH__(+ ,TOTAL DR,%WOOWN_�-.:(FI.) <br /> TOTAL DEPTH OF COMPLETED WELL ',Way-not be, represmjative of a weld's fang-tern yield <br /> DEPTH' BORE- CASING ISI _ DEPTtt ANNULAR MATERI AC <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> �—�— DIA: z ti MATERIAL 1 INTERGAUGE Stu,GAUGStu, SIZE -- CE- BEN- <br /> GRADE(t et es) ul $ s GRADE DIAMC1cR OR WALL - IF ANY. MENT_iDNtTE ,=ILL FILTER PACK <br /> Ft. to FL m ; pr�d�es} THICKNESS (TYPE/SIZH <br /> T"'^�� __—r` — � .� � Fes'' '✓�^^e.� —_Il _' ��f =��- <br /> -'- — <br /> : r <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> 1:the undersigned,certify that this report is complete and accurate to.the beat of my knobi(edge ard;be(iet., <br /> Yv _ Gecyogic Log <br /> — Well Construction Diagram NAM.4' t 1PRIFATI tet -- <br /> iFr.RSON.FIRM.n i.17P.P6RATlt}N}¢ t PED I)R PIt TED) <br /> — Geophysical Log(s) <br /> Soil/Water Chemical Analyses <br /> Other / <br /> SI rxJ--•------�.....,•..y, ._-_— l f d •— h "ter <br /> ATTACH AODlACNYAL lNFYJAMATION, lF IT EXIATS• g g";7 UC`a1SED WATER MFU—COMRnE1�OR DATE SIGNED ' (.-5T tIL'FNu Ntlt.f6 - <br /> rnvTt tau XEV.05.03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> loonseuu@A II19 wOs_:l £L Z£VOLS I b I (J-W J)ZS:Ov t LZ-L0-600Z Ot IO g abed A)P!N:01. <br />