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QUADRUPLICATE STATE OF CALIFORNIA I--D W R USE ONLY — DO NOT FILL I N <br /> For Local Requirements a WELL COMPLETION REPORT <br /> Page of <br /> i �, Refer to Instruction Pamphlet STATE WELL NO./STATION NO.Owner's Well No. No. 515535 Ll ❑ <br /> Date Work Began ' , Ended f I LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No. Permit Date f` APN/TRS/OTHER <br /> GEOLOGIC LOG u_ WELL OWNER <br /> ORIENTATION (`�) VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name -- <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address y ) E <br /> DEPTH FROM i`Y' .> <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY WELL LOCATION STATE ZIP <br /> Address <br /> .t City .. <br /> County <br /> APN Book Page Parcel l <br /> or <br /> Township Range '' Section (` <br /> or <br /> Latitude NORTH Longitude WEST <br /> DAG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (_!L)— <br /> NORTH <br /> ✓)NORTH <br /> i _ NEW WELL <br /> 1 <br /> _ <br /> MODIFICATION/REPAIR <br /> _Deepen <br /> C. _.......................—_ —Other t (Specify) <br /> i i ....—......ti....----- <br /> �..., _DESTROY(Describe <br /> i t Procedures and Materials <br /> ' Under"GEOLOGIC LOG") <br /> PLANNED USE(S) <br /> a � ) <br /> MONITORING <br /> .''t ,. WATER SUPPLY <br /> Domestic <br /> 'i`i if•.i J Public <br /> Irrigation <br /> I i <br /> -!1 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 /> I <br /> DRILLING i <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED ( <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 CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE FROM SURFACE TYPE <br /> r i MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> DIA. w CE- BEN <br /> o - DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) ¢ w o� J GRADE MENT TONITE FILL <br /> Ft. to Ft. » (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> I,the un rsigned,certif that this report is complete and accurate to the best of my knowledge and belief. <br /> — Geologic Log 71VC_ t 4 <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM OR CORPORATION) (TYPED OR PRI ED) <br /> Geophysical Log(s) ..-r ,•� f _ f( l;i. / � A /��+ <br /> Soil/Water Chemical Analyses <br /> ADDRESSCITY STATE ZIP <br /> i <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />