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ORIGINAL Sl lir l)f l \I 1f 01{\11 DWR USE ONLY — DO NOT FILL Irl <br /> File with DWR WELL COMPLETION REPORT FSTATE WELL NorsrnnON NO <br /> Page �oi'.� Refrr to lrislrrrFlrr++e Prrnrl+lrlel ❑ ❑ <br /> + o..Tier s �vLll v— i "° 811084 <br /> D lte N�ori. Began Z9 Ended 1 01-t.9Q$ _ _ LATITUDE LONGITUDE <br /> Loc Il Perintt ��,enc� g Ce U S + <br /> APNlTRSIOTHER <br /> • Pt,riiilt \o S S Pe-tuft U Lte <br /> GEOLOGIC LOG NVELL O�NNER <br /> ORIENTATION (!? A—VERTICAL —HORIZONTAL ANGLE —(SPECIFY) \r dile ��� � � � u ' 1L <br /> DRILLING [ �} �lalluirl �cFclress L' <br /> DEPTH FROM METHOD ++ _Ak Y r_ FLUID_�1 O f� �:. <br /> SLfa"" DESCRIPTIO\ OC r/ Z Z <br /> Ft to Ft Dr sr rib, niatlIml ,r,r (olor r tc CITY srarE ZIP <br /> —NIE <br /> Acldscss <br /> S�1 ESS'FL�tr��k�TWeet <br /> Clt% C <br /> Coling 'SOK 0 Iq IQ <br /> -�P\ Book PIgE I9 PIt CEI <br /> To\vnslnli Rang( SI 01011 <br /> r i L itltilde I I NORTH LonzgItl IBL, I I NEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOC ITIO\ SKETCH (CTIA ITS <br /> NORTH NEW WELL <br /> t i MODIFICATIONIREPAIR <br /> Deepen <br /> Other(Speoty) <br /> tci <br /> o G DESTROY(Describe It <br /> Procedures and Materialss I Under GEOLOGIC LOG) <br /> 5 f P �a PLANNED LSES t:f�) <br /> l WATER SUPPLY <br /> Domestic PLehC <br /> Irrigation Industrial <br /> s r W MCNITCRING i <br /> TEST WELL <br /> r l CATHODIC PROTECTION <br /> HEAT EXCHANGE <br />' 1 I <br /> DIRECT PUSH <br /> S <br /> l I INJECTION I <br /> a i VAPOR EXTRACTION <br /> r I SPARGING <br /> i I SOUTH REMEDIATION <br /> 11111strrrte or Desenbc Datance of Ildl(ro+I.Runds 6iuldtns <br /> r I FcorLs Rrurs etc and attar a inrrjj+ sc adchtiorud aper f OTHER(SPECIFY)�. <br /> nc cessarr� PL.E 45E RE ACCURATE&COILPLET� <br /> 11 ATER LEN EL 8 MELD OF COMPLETED 11 ELL <br /> I i <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i DEPTH OF STATIC @e 1 1 11 C V` 1 s f 9 Q <br /> WATER LEVEL GQ {{ � (Ft)8 DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE++�� 4 <br /> TOT IL DEPTH OF BORI\C (Ft et) TEST LENGTH i L (Hrs) TOTAL DRAWDOWNYL.._—(Ft) <br /> TOT 1L DEPTH OF COMPLETED 11 ELL (Feet) 'May nor be reps esenrart.e of i ;.ells long-temp yield <br /> CASING (S) DEPTH ANNULAR NIATERIAL j <br /> DEPTH BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(_) <br /> DIA x z a a MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN 4 <br /> (Inches) z "' za GRADE FILTER PACK <br /> w a DIAMETER OR WALL IF ANY MEN7 7DNITE FILL <br /> Ft to Ft m v �� (inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> 5 $ va z !94kO l 3 ✓ <br /> z C7 V C- zst-It4v 0' Q10 <br /> 2 S a h <br /> i <br /> 1TTaCHN1E\TS (.!:a) CERTIFICATION STATEMENT <br /> I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Geologic tog W l'! ,K *jK G. <br /> V + r 1 <br /> Well Construction Diagram NAME(PERSON FIRM OR CORPORATION} (TYPED OR PRIMED) <br /> • Geephysica)Log(s) P` �y' R o X J r y 1�+`a V I S to CA 9�5 <br /> Soil/Wale,Chemical Analyses V <br /> Other 5 i ft f 4 h— ADDRESS CITY STATE 210 <br /> ATTACH ADDJTICNAL INFORMATION 1F iT EXISTS Signed42 /,,, /gg zo 19NU <br /> WEL R0.LERlA 0 IZE RE AESENTA1iVE DAT SIG D C 57 LICENSE NUMBER <br /> D"lt ISS REI It q- IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />