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ORIGINAL STATE OF CALIFORNIA10,fD w R USE ONLY — 00 NOT FILL 114 <br /> File with DWR ELL COMPLETION REPORT <br /> � � Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Page�of <br /> Owner's Well No. C 515532 0 <br /> Date Work Began <br /> 312-0 1 CC , Ended �/ �� ) � LATITUDE LONGITUDE <br /> Local Permit Agency. th �oL 1,1 t (% APN/TR / TH R <br /> Permit No. 2- k 1 `i Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!!L VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address f' Q VX 1, C q Sgs <br /> DEPTH FROM DESCRIPTION 'SewGtrr"�-v-�-' <br /> SURFACE CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL LOCATION <br /> C Address 19 S 1 <br /> City <br /> 2 'C t h C County �c K\ <br /> b �C APN Book Page Parcel S _ <br /> C( L C Tow onship_��Range��Section \ <br /> Latitude i NORTH Longitude WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> U S Ci CA'F• LOCATION SKETCH ACTIVITY (�) <br /> NORTH S rrEw WELL <br /> i MODIFICATION/REPAIR <br /> _Deepen <br /> ' t 1' Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> A� I FJIIJr PLANNED USE(S) <br /> CALtv < (2L)F <br /> � 3 w MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> C I/1 �� (^ 1 CQ A , Public <br /> S VV 4u�- ( CID Irrigation <br /> Industrial <br /> ..TEST WELL.. <br /> �. �V-\ (74% <br /> r, a&,A CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(specify) <br /> C such as Roads,Buildings,Fences,Ricers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING <br /> �- J METHOD k�Z Im 190 FLUID <br /> WATER LEVEL & YIELDdFCOMPLETED WELL <br /> DEPTH OF STATIC ♦j 7) <br /> -- ' - WATER LEVEL —(Ft.) & DATE MEASURED <br /> On <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 41---1—(Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) Way not be representative of a well's long-term Yield. <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE <br /> r z d INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> ER PACK <br /> o _ DIAMETER OR WALL IF ANY MENT TONITE FILL FILT <br /> DIA. MATERIAL/ <br /> Ft. to Ft. <br /> (Inches) �? J GRADE (inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> m N a <br /> o o <br /> ATTACHMENTS (v�L) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <br /> Well Construction Diagram NAME <br /> (PERSON, . CORP TI (Ty�6 OR <br /> ryN p) /� //��'' 9 <br /> PIK <br /> Geophysical Log(s) � �L Oil? <br /> / �/� Z" C• - STATE �a <br /> Soil/Water Chemical Analyses CITYZIP <br /> Other <br /> ADDRESS <br /> _ <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed n DATE SIGNED C-57 LICENSE NUMBER <br /> WELL DRILLER/ ORIZED PRE ENTATIVE <br /> DWR 188 REV 7,-so IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />