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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> ` File with DWR ELL COMPLETION REPORT <br /> Page Of__L Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. 515540 701 <br /> Date Work Began 3 2,q _/ , Ended �/ 'Z`./C c LATITUDE LONGITUDE <br /> Local Permit Agency ( c <br /> El�O �� APN/TRS/ THER <br /> Permit No. OOL2 1 y Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION ('�) VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name Sohh `ate)k r FtQ-x 1,> rs <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address i s <br /> DESUPTH <br /> DESCRIPTION -� CA- 9�gsi <br /> CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain rize,color,etc. WELL LOCATION <br /> S cC C 1— Address i&19 ", <br /> City V\ <br /> County C:e <br /> 1 C L APN Book Page Parcel <br /> U or <br /> Township-KL Range 10 E Section 1 G <br /> or <br /> ( C Latitude NORTH Longitude WEST <br /> � '` DEG. MIN. SEC. DEG. MIN. SEC. <br /> L/ LOCATION SKETCH ACTIVITY (±L)— <br /> L—) <br /> NORTH C' , �W WELL <br /> is'sS A v\cwa- �+�%---1 MODIFICATION/REPAIR <br /> _Deepen <br /> _Other(Specity) <br /> a &L 1 <br /> tC)CL —DESTROY(Describe <br /> Procedures end Materials <br /> Under"GEOLOGIC LOG') <br /> v ��� PLANNED USE(S)_ <br /> 3 w '(—) <br /> IMONITORING <br /> WATER SUPPLY <br /> r lL; ( t'l r, i I Domestic <br /> Public <br /> Irrigation <br /> l ( 'Y', Industrial <br /> "TEST WELL" <br /> ICATHODIC PROTEC- <br /> �^ SOUTH TION <br /> 47 Z ' C VI,4 Illustrate or Describe Distance of Well from Landmarks OTHER(Speeity) <br /> U t� C L such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING <br /> METHOD Hit 1 -�% QA-112 FLUID <br /> WATER LEVEL & YIEL OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL 11.1 (Ft.) & DATE MEASURED J <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING Vh (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL — (Feet) " fav not be representative of a well's long-term Yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE .t� <br /> DIA. z o _ MATERIAL/ INTERNAL GAUGE SLOT SIZE ME <br /> TE�(Inches) a oz� J GRADE DIAMETER OR WALL IF ANY FILL FILTER PACK <br /> Ft. to Ft. m �o (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> (IL) <br /> c, 3j, LiL <br /> ZT 4 ) G <br /> i <br /> ATTACHMENTS (i!L) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this repot is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <br /> Well Construction Diagram NAME v I �I—/ d <br /> (PERSON, FIR RPORATION) (TYPED bR IINTED) /�j� ��� <br /> Geophysical Log(s) Plead (na / � <br /> Soil/Water Chemical Analyses STATE ZIP <br /> ADDRESS CITY /�/�,�� <br /> Other j/ � �n�,L 1 <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed DAT SIGNE C457 LICENSE NUMBER <br /> WELL DRILLER/ HORIZED REPRESENTATIVE <br /> DWR Im RE%. -90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />