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IGINAL STATE OF CAL(FORMA WR U19 oaf Y o o N O V FILL i <br /> File with OWR WELL COMPLETION REPORT � �,,n `' t` ' � <br /> Referfa IN11ruetloa P4mpblet STAT )NELL NO IVATM NO <br /> (hvrtces Well No y No55 <br /> J� <br /> Date Work Began ,n 2•" �. � LATITUDE LONGITUDE <br /> Local Permit Agcnc r7- <br /> Permit Na Permit Date 7— <br /> G$OLOCIC LOG FYELL OW}Y t; <br /> ONEWATION (.K) _M71CIL __Hopno"AL _MaLlr Natltt' <br /> faePTtt FRcr<s CIXM To FIM WATER (FL)BELOw SUUpACE , M 4 Adc]Te 0/ <br /> "SURFACE 1 DESCRIPTION <br /> Ft to Ft. Ilacrnc�watmd,grate nm ofor,sae, I ` I ` • STATE ZtP <br /> 00Tf EL L,'T,� <br /> r, , <br /> W `1Address I <br /> ' J ' _ �t�\�.i� r 1 <br /> AFN Book `y Page Parcel <br /> $ r • '' a <br /> TR`o's)up�Range Section JA <br /> ,AI 7ttidE-- 1 1 NORTH <br /> I <br /> ■*�pY� i- CEG MSR_ SEC �OYfglttlC�e. oE0 ` 'r 9 VYSrf <br /> LOCATION SKETCH ACTIVITY (✓} <br /> NO NEW WELL <br /> ��pp■■e� 4 <br /> 1 , 1 <br /> 1 <br /> ��� _Oilier(Specify) <br /> , i p)6ST#70Y(AeecnT�r <br /> 1 � Prpc■aLrea■pdMereffala <br /> IMdw1affuLoo1C LOCI I <br /> 1 ' PLANNED USES) <br /> MGNITORINg <br /> , i WATER SUPPLY <br /> t , <br /> Public <br /> , , � irefaatian <br /> 1 1 <br /> _ kawUf41 <br /> >Z7` 'TEST WELL <br /> 1 r <br /> SOUTH T� TIC <br /> ODIC ORO <br /> 1 1 <br /> MmIrale at Describe Distaam of Weft from I.4adraarb OTHM(specify) <br /> 1 1 such as Asada.Bufldfngs,Paaces Risersefe <br /> PLEASE HE ACCURA4$6 COUFLiA <br /> ' DRILLING � <br /> METHOD FLUID <br /> ' WATER LEVET, & YIELD6F COMPLETED WELL <br /> t , OEPTtt OF STATIC <br /> t WATER LEVEL (FI) & DATE MEASUnED <br /> ESTIMATED YIELD' ({TPM) A TEST TYPE <br /> TOTAL DEVI`H OF BORING (Feet) TEST LENGTH Qua) TOTAL DRAWDOWNS (Fs j <br /> TOTAL DEPTH OF COIIMPLETED WELL i—. (Pest) •May not be repreufrrmme of a well's fang-tcrm yield <br /> OEPTH SORE CASCNG(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPS <br /> AIIATERIALt INTERNAL GAUGE SLOT SIZE <br /> ham) i A4E DIAMETER OR WALL IF ANY CE- tIEH FILTER PACK <br /> FL to Ft pnahee) THICKNESS (inches) Ft to Ft MINT)0N1TE FILL <br /> (✓ ) ( � (✓) (TYPHISIZE) <br /> LQ1 <br /> 1 , <br /> I ' <br /> 1 <br /> l i <br /> ATTACHMENTS (z�) CERTIFICATION STATEMENT <br /> fl■alogia Lop 1,thee <br /> u dralgnod,cattily that this report is complete and accurate to the beat of my knowledge and belief <br /> Wo Coa3IrQ■ophYakel LoLOOM)uattoa Dlapr■m NAI,fF 1 <br /> r 4. "WA,OR COMMON) [IMI) ON pIN75g) <br /> — SoIUWalarChem"Ant"as G�r� /� A <br /> � .y W✓ <br /> !� <br /> �q;► .,J f i �'4' <br /> AUOAFSS Dislmay!� �A CITY '% �zi;#IE TIP <br /> Met l !+ <br /> ATTACH ADVITTOAiAL WFORMATIOAL)F 1T EXISTS. &p0 plT REM BATE SIGNED C57 LICENSE <br /> NUMBER <br /> DWRlea REYToo IF ADDITIONAL SPACE IS NEEDEE) USE N ECU7IVELY NUMBERED FORM � D <br />