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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR •WELL COMPLETION REPORT STATE WELL NO./STATION NO. <br /> Page_L_of Refer to Instruction Pamphlet ❑ 11 11 ❑ <br /> Owner's Well No. %A l�� 3 "° 515 5 3 5 <br /> LATITUDE <br /> — LONGITUDE <br /> Date Work Began=3c ' Ended �— <br /> Local Permit Agency S APN/TRS/ TH R <br /> Permit No. Men,02 a 1,�1. Permit Date 3r tc G <br /> GEOLOGIC LOG 1, WELL OW,.N}�E+R+ <br /> ORIENTATION (2!L) —VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Name Sin n �����^ ��'' ' `l l <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address P.C 12>0.x S <br /> DEPTH FROM DESCRIPTION �'r t QVrt�v i S Frs i <br /> SURFACE CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL LOCATION <br /> Address <br /> ri ,.� (C City <br /> County 'Scin 5mr A I h <br /> I-1 <br /> 15 APN Book Page Parcel 3' <br /> Township��_Range _Section (G <br /> or WEST <br /> LatitudeNORT(i Longitude <br /> _ DEG. MIN. SEC. DEG. MIN. SEC. <br /> 7. LOCATION SKETCH ACTIVITYO <br /> NORTH _ NEW WELL <br /> _ (x L_ MODIFICATION/REPAIR <br /> Deepen <br /> c. r Other(Specify) <br /> 0-T <br /> i ' DESTROY(Describe <br /> ProceUnder ures"GEOLOGIC <br /> Materials <br /> Under"GEOLOGIC LOG") <br /> L , r rk <br /> (co IDf-1 lju�i PLANNED USES) <br /> I <br /> ul MONITORING <br /> l�� <br /> WATER SUPPLY <br /> I( Domestic <br /> Public <br /> CL <br /> W Y <br /> ,Ql1 Irripetion <br /> i -56 V" Industrial <br /> boc <br /> C _ _ — .TEST WELL. <br /> u PLPCATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING 11Q ��VY� &Y.r FLUID <br /> METHOD_, <br /> WATER LEVEL & YIELD F COMPLETED WELL <br /> DEPTH WATER OLE LEVEL <br /> 1 v`4 (Ft.) & DATE MEASURED ;NQ I G <br /> ESTIMATED YIELD' (GPM) S TEST TYPE <br /> TOTAL DEPTH OF BORING _15,._(Fee) - TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL —2.._� (Feet) May not be representative of a well's long-term yield. <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE <br /> FROM SURFACE HOLE TYPE TYPE <br /> INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. r z . a MATERIAL/ FILTER PACK <br /> o DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> (Inches) a o� GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> Ft. to Ft. m y o LL <br /> © ✓ �G 0 <br /> � 3 10 <br /> ✓ i i <br /> ATTACHMENTS (iL) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and aceturate to the best of my knowledge and belief. <br /> Geologic Log /'� _ / T� <br /> Well Construction Diagram NAME IRM, OR �i <br /> (PERSON, FIRM, CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 9-f-V L�jfi� J zmn�m` <br /> Soil/Water Chemical Analyses V �7(J[+ G(ADDRESS CITY STATE ZIP <br /> Other xz I%/ 202 <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed DATE SIGNED C-57 LICENSE NUMBER <br /> WELL DRILLER/AU ORIZED REPRESE TATIVE <br /> DWR IaxREV 7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />