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0HIlU1NAt_ N I A I t; u)• C Ai Ii-OKNIA <br /> File with DWRf WELL COMPLETION REPORT ° l -11 IDL 3 O <br /> Page I Of + Refer to Initrvrt,on Pampblcr STATE WELL NO iSTAT10N NO <br /> Owner's Well No j No 544411 E <br /> Date Work Begin � Ended / 9 LATITUDE LONGITUDE <br /> Local Permit A e UI <br /> l 1 — <br /> Permit No Permit Datt <br /> GEOLOCIC LOG WELL O"NrER <br /> RIENTAT10N (t ) VERTICAL _ HORIZONTAL — ANGLE _ (SPECIFY) Name <br /> DEPTH TO }.IRST %%ATERt IFt) BELOW SURFACF h4giling�rreess..1 r E�� SO CA <br /> DEPTH FROM rllA <br /> SURFACE DESCRIPTION A <br /> Ft to Ft Derrnbe-matertal grain rise color etc CITY STATE ZIP <br /> S 7vp�/G 11 EI L LOCATION <br /> Address <br /> SAAJD <br /> Cih <br /> 1 A CountN 1 <br /> : 514k,`6 APN Book Page Parcel <br /> 4 !� i 5_3 C,�_A 5-'FETownship R.ingr Section <br /> n or <br /> IJ ],,,atltlldP NORTH Longitude WEST <br /> CD <br /> L.1/ir DEG MIN SEC DEG MIN SEC <br /> LOCATION SkETCHCL-14 -YCTINITt (.:L)— <br /> /'f AIRED CL-14NORTH ;- NEW WELL <br /> (✓ ' "t) MODIFICATION I REPAIR <br /> o CLAP , — Deepen <br /> 1 fV Other(Specify) <br /> +o .SAND — DESTROY(Describe <br /> ProceduresrndMaterters <br /> V Under GEOLOGICLOG) <br /> JAF ; IZd SA A.1b f PLANNED USES) <br /> o�s C L/a w Uj f ) <br /> 6.4A <br /> r � W MDNITORING <br /> rr'`� WATER SUPPLY <br /> 4"'0 ED CLAY Domestic <br /> _ Public <br /> a � __,_ lrngatron <br /> Industrial <br /> TEST WELL <br /> ...T CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Desenbe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> METHOD ?�Aa FLUID FILM <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (FI) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 137— (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL �o (Feet) May not beTepresewarive of a wells long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> DIA z d MATERIAL DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> (Inches) a o� d GRADE MENT TOWTE FILL <br /> Ft to Ft (Fiches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> D : ria 17 o 141 :53011;?2L, O 100 1 ✓ <br /> 110 t30 iZas It C.9 •o4'0 <br /> ATTACHMENTS (:) CEAT1FICATION STATEMENT <br /> Geologic LOU I theun rSigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME <br /> Te;ZF3ETd $�E INA 917, INC- <br /> (PERSON FIRM OR CORPORATION)k PED OR PRINTER) 11 1/1 /� (/�/] <br /> Geophysical Log(s) t ) Irl)Y ! ot)csro ai 5 <br /> �._ Soil!Water Chemical Analyses �✓� ZIP <br /> ADDR CITY STATE <br /> ) other � 7 Z 6 �����O <br /> ATTACH ADDITrONAL INFORMAT)OV IF IT EXISTS Sip <br /> AUTHORIZED EPRESENTATIVE - 0,41q <br /> SI fD C 57 LICENSE NUMBER <br /> DWR IhhREV 7 90 IF ADDITIONAL SPA NEEDED USE AEXT CONSECUTIVELY NUMBERED FORM �D C� <br />