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ORIGINAL STATE OF CALIFORNIA IT DWR USE ONLY - 00 NOT FILL IN <br /> File with DWRI ELL COMPLETION REPORT STATE WELL NO./STATION Q. <br /> Page_L Or 4f Refer to Instruction Pamphlet ❑ <br /> Owners Well No. N w-4 No. 515533 <br /> Z,D Q O LATITUDE LONGITUDE <br /> Date Work Began 3 2fl �O , Ended 3 <br /> Local Permit Agenc ix.✓1 v <br /> 26 OO APN/TR / TH R <br /> Permit No. QyO Z Z I-7:± Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> a o ,r <br /> ORIENTATION (�) _VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Name pp <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address 2-U <br /> DEPTH FROM DESCRIPTION Sa-e'ro,.yVU -1+n <br /> SURFACE CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL LOCATION <br /> t J L Address r U <br /> h City <br /> County " I _ O^ <br /> ►JC <br /> (d t� C APN Book Page Parcel ^200 J <br /> Township or Range Section <br /> Latitudeor NORTH Longitude WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> -� L LOCATION SKETCHACSIVITY (�) <br /> NORTH _/NEW WELL <br /> i MODIFICATION/REPAIR <br /> _. _. = __ _�I _Deepen <br /> W h • _Other(Specify) <br /> I�4r�iv1©J Sei <br /> _ tl DESTROY(Describe <br /> Procedures and Materials <br /> ez Under"GEOLOGIC LOG') <br /> I- PLANNED USE(S) <br /> MONITORING <br /> ce— -WATER SUPPLY <br /> � ---. L f Domestic <br /> Public <br /> i I V I 7d_AA Irrigation <br /> Industrial <br /> '.TEST WELL" <br /> _ CATHODIC 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 I <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH F WATER OLE ELATIC ' #�t) & DATE MEASURED <br /> �oo <br /> ESTIMATED YIELD` (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May 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 /> INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. x W o - MATERIAL/ DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> (Inches) < W oz� J GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> Ft. to Ft. <br /> r3 sa, 2 It <br /> If I , z ✓ <br /> Zt <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> I,the under'gned,ceer�tify that this <br /> report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log CJ/ �' 1C /a t �� <br /> Well Construction Diagram NAME(PERSON, FIRM, 0 CORPORATION) (TYP PRINTED)-�� � y� <br /> Geophysical Log(s) �.{/w p 00 �YlZZ466 l? / /5- ZIP <br /> Soil/Water Chemical Analyses r�/VVVV V f/4 ,/! CITY v/STIATE ZI�P[.�� <br /> ADDRESS <br /> Other c 17 O� ��/Kr_ <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed DATE SIGNED C-57 LICENSE NUMBER <br /> WELL DRILLE AUTHORIZED�RESENTA�TIVE ��� <br /> DWR 18811EN'."-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />