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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 T of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. <br /> No. 515534 Ll <br /> Date Work Began , Ended LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No. i Permit Date APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (i�L) VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. <br /> WELL LOCATION <br /> Address <br /> ` City <br /> County <br /> APN Book Page - Parcel <br /> or <br /> Township Range Section <br /> i r <br /> Latltoude i i NORTH Longitude i WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (✓) <br /> NORTH y/-jEW WELL <br /> MODIFICATION/REPAIR <br /> _Deepen <br /> i <br /> _Other(Specify) <br /> t a <br /> 1 <br /> DESTROY(Describe <br /> ✓ �� Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> f J PLANNED USE(S) <br /> ?� LLI MONITORING <br /> i �......... WATER SUPPLY <br /> iDomestic <br /> Public <br /> i Irrigation <br /> Industrial <br /> S `�• �rlf "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH iTION <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 +� <br /> ESTIMATED YIELD" (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING s (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL ;r (Feet) May not be representative of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> BORE- <br /> FROM SURFACE HOLE TYPE(.!L) FROM SURFACE TYPE <br /> Yo d MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> DIA. W CE- BEN <br /> (Inches) a z� a DIAMETER OR WALL IF ANY FILTER PACK <br /> MENT TONITE FILL <br /> Ft. to Ft. n ti opo LL GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> i <br /> ATTACHMENTS (2L) 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 k t <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) ., <br /> Soil/Water Chemical Analyses ' f F' r" ' .""1'• '' ! r / t �F.. f <br /> ADDRESS � Com— ZI STATE ZIP <br /> Other ,r . <br /> Pi r <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> .• WELL GRILLER/AUTHORIZED REPRESENTA IVE DATE SIGN C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />