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QUADRUPLICATE > SATE OF CALIFORNIA D W R U ONLY — O NOT FILL I N <br /> For Focal Requirements i WELL COMPLETION REPOR <br /> Page of ,j, Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No 4 s�L j b la �� ( �;J(��I�'id 1w ❑ ❑ <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agency <br /> �� ., +„ " I I I I-, � i t �, + . i,tr����IT SERVlCE <br /> Permit No J a R <br /> Permit Date <br /> GEOLOGIC LOG 8 Fit! 2: 1 WELL—OWNER <br /> ORIENTATION (✓) VERTICAL HORIZONT ANGLE _(SPECIFY) Name � ` t �� '� i C <br /> DEPTH FROM DEPTH TO FIRST WATER—(FI)(Ft) BELOW SURFACE MaTltff,'�rdress �{� 1� <br /> SURFACE DESCRIPTION <br /> F1 to Ft Describe material,grain size,color,etc CITY STATE ZIP <br /> j WELL ILOCATI�)�l <br /> Address <br /> City — v <br /> d j County <br /> APNefBook Page Parcel <br /> Township Range Section <br /> Latitude l NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH /ACTIVITY (i`)— <br /> NORTH <br /> i`)NORTH NEW WELL <br /> MODIFICATION I REPAIR <br /> L I" 'y I �' —Deepen <br /> —Other(Specify) <br /> L j + <br /> ' �i vyf ri.{< 1✓` r u e w S C�' 1 t$If in� i —DESTROY(Dsscnb <br /> C e <br /> l.1 Procedures end Matenafs <br /> Under GEOLOGIC LOG) <br /> r *, E <br /> L c � s�� <br /> 4S 5t I PLA�vNED USE(S) <br /> Lu MONITORING <br /> i <br /> WATER SUPPLY <br /> „ .,...,� Domestic <br /> • i i .+ ' I f.. + s '" + e,,v )` �. Public <br /> j' tl ii E iL ,ri t +i Irrigation <br /> t .1t Industrial <br /> i <br /> TEST WELL <br /> r — CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> { t ) / o ,,r rt such as Roads Ruddings Fences Rivers etc <br /> PLEASE BE ACCURATE dr COMPLETE <br /> e �^ It°„�f- S j r Vt r ) I r k <br /> DRILLING <br /> t ' METHOD FLUID <br /> r"jrr `i WATER IEVL & YIELD OF COMPLETE D WELL <br /> DEPTH OF STATIC I J 1 U <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD` (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 1 ( F1, TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELLy (Feet) *May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE _ FROM SURFACE TYPE <br /> DIA TZ �_ _o a MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN(Inches) aGRADE DIAMETER OR WALL IF ANY MEENT TONITE FILL FILTER PACK <br /> Ft to Ft cio = (Inches) THICKNESS (Inches) Ft to Ft (� ) (� ) (� ) (TYPElSIZE) <br /> n <br /> -i 15 a, i I <br /> ! 4kx <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> . Geologic Log I,the un ersigned gertlfy that this report Is co%plete and accurate t0 the best of my knowledge and belief <br /> ��lS. 'i �/`�•"'' � �, �t i t = `{ J � �F � •+t <br /> Well Construction Diagram NAME M ! <br /> (PERSON FIRM OR ORPORATIlO_N) (TYPED OR PRINTED) /t <br /> Geophysical Log(s) 1 2 I �'1 l i!, r ? J It P ^�V tj �t fr 1 1 ��LI ( [ f S D <br /> Sod/Water Che ica��lnel sas f✓]" �~+` <br /> T 1 ' 1 t` { ADDRESS CITY STATILI <br /> E ZIP <br /> Other_ t _ � + <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS -ed W12LL DRILLER AUTHDRIZED REPRESENTATIVE DATE SIGNED __C57 LICENSE NUMBER <br /> DWR188REV 7917 IF ADDITIONAL SPACE IS NEEDED, USE/ EXT CONSECUTIVELY NUMBERED FORTONFIOENTIA <br /> ff� iBl 1i�U1 9LL� <br />