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QUADRUPLICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page.of_�_ Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. `�`�`-t� .� No. 515532 <br /> Date Work Began Ended - LATITUDE LONGITUDE <br /> i.. <br /> Local Permit Agency <br /> Permit No. ! Permit Date ! f f C APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (`�) _ j/VERTICAL _ HORIZONTAL ANGLE _(SPECIFY) Name f -- <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address k. <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> ' <br /> Ft. to Ft. Describe material,grain size,color-etc. CITY WELL LOCATION STATE ZIP <br /> l Address t t <br /> City ) <br /> County I <br /> APN Book Page Parcel <br /> or <br /> Township-, Range Section <br /> or <br /> Latitude I NORTH Longitude I I WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (✓) <br /> 4 NORTH _„11EW WELL <br /> MODIFICATION/REPAIR <br /> ,, ,. ...�._.. —Deepen <br /> -. —Other(Specify) <br /> DESTROY(Describe <br /> ( r -� `•t' ~., ._ Procedures and Materials <br /> ' Under"GEOLOGIC LOG') <br /> PLANNED USE(S) <br /> U) a (�) <br /> W �L'MONITORING <br /> - - WATER SUPPLY <br /> ' Domestic <br /> L Public <br /> Irrigation <br /> f Industrial <br /> i <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 <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED 1 <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH Mrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) #May not be representative of a well's long-term yield. <br /> DEPTH BORE- <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE (✓) FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA. Y w o MATERIAL/ CE- BEN <br /> (Inches) a =� d DIAMETER OR WALL IF ANY FILTER PACK <br /> MENT TONITE FILL <br /> Ft. to Ft. m c o"Q LL GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> ATTACHMENTS (zL) 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 Xt <br /> ( .. .1 <br /> — Well Construction Diagram NAME ly + <br /> (PERSON, Fa _OR CORPORATION) (Y�P„EU OR P INTED) <br /> — Geophysical Log(s) <br /> — Soil/Water Chemical Analyses <br /> ADDRESS ,+ �s' CITY STATE ZIP <br /> Other „rf.✓ fi f ...... <br /> / j. 1 d ar <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed , - + , r .. ' <br /> WELL RILLER/ HORIZED'R PRE ENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />