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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT F I L I N <br /> File with DWR WELL COMPLETION REPORT I I I I I I I I I I <br /> Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Page�of� 515534 0 <br /> Owner's Well No. / No. <br /> Date Work Began <br /> 12-0 r00 Ended 120 (00 LATITUDE LONGITUDE <br /> Local Permit Agenc `� � <br /> ,� ^ APN/TRS/ THER <br /> Permit No. l'L(L��J—� Permit Date !—�/ <br /> GEOLOGIC LOG WELL OWNER <br /> ERTICAL _HORIZONTAL _ANGLE _ (SPECIFY) Name r I <br /> ORIENTATION (—) VO Z <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address Cia- IT S� <br /> DEPTH FROM DESCRIPTION <br /> SURFACE CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL L 0 C A ION 1 <br /> �- m OvlR1�T <br /> Address <br /> City l 6 <br /> r 6J I-- Count' —asAPN 3 - 2VO <br /> Book Page Parcel ' <br /> Township. Range 6 Section <br /> GL °f WEST <br /> Latitude NORTH Longitude <br /> DEG. MIN. SEC. DEG. MIN. - SEC. <br /> LOCATION SKETCH AC IVITY (!) <br /> NORTH NEW WELL <br /> O _ — MODIFICATION/REPAIR <br /> 14 <br /> I _Deepen <br /> L „ _Other(Specify) <br /> TT Llou sa- <br /> N DESTROY(Describe <br /> Procedures and Materials <br /> _ Under"GEOLOGIC LOG') <br /> IPLANNED USES) <br /> rpay <br /> to <br /> (�) <br /> w w MONITORING <br /> WATER SUPPLY <br /> 2A F3 (It iA o <br /> Domestic <br /> Public <br /> 046 ID LIS' <br /> Irrigation <br /> L t��,o2T1� <br /> D r � Industrial <br /> "TEST WELL" <br /> 1 ^ CATHODIC PROTEC- <br /> SOUTHTION <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 <br /> METHOD w J <br /> ' �K_FLUID <br /> WATER LEVEL YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC i/ ..�� �' 3 Loo <br /> LEVEL (Ft.) & DATE MEASURED <br /> q ` ESTIMATED YIELD (GPM) & TEST TYPE <br /> F <br /> TAL DEPTH OF BORING 21 , (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TAL 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 /> c w o i MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. FILTER PACK <br /> DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> (Inches) a w zoo J GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> Ft. to Ft. m N �o <br /> 13 G SZ. O D <br /> Z . o Z iZ <br /> of <br /> ATTACHMENTS 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(PERSON, R CORPORATION) (TYP OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses ADDRESS vV CITY ��'t y(jj/ STATE ZIP <br /> Other / <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed WEDA SIGNFD C-57 LICENSE NUMBER <br /> LL DRILLER/AUT RIZED RE SENTATIVE <br /> DWR 188 REV,;-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />