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OIMGINA� STATE OF CALIFORNIA R U s F On/Y _ 00 1 r <br /> File with 17 R WELL COMPLETION REPORT '� 0 <br /> Page of ` Refer to Instruction Pompblet STATE WELL NOISTATtON NO <br /> OWner'S Well Ng — ND. 42961& <br /> 296 ❑ ❑ <br /> Date Work Began Z^D ,Ended <br /> LATITUDE LONGnum <br /> Local Permit Agency I C <br /> Per61mit No _ -'1-9 - PNt s Tri FP <br /> �� � Permit Date �� <br /> GEOLOGIC LOC ,WtELL OWNER <br /> ORIENTATION ( : ) VERTICAL �HORIZONTAL —ANGLE —(SPECIFY) Name � v Y- d A. <br /> DEP)TI TO FIRS('WATER (F.)BELOW SURFACE Ma,link�aaj'10410"4 <br /> D SU=RFACEM DESCRIPTION 1 3 _ <br /> Ft to FtDeimbe mar grmn size rotor,etc ; W.FY I W E L t T,Q C A T I ON STATE ZIP <br /> , i s <br /> �• '� Address 3r <br /> h - 5 <br /> ' Y y l City <br /> 1 r r <br /> ' - tA CoiTnky €1i r, ml V_L_ <br /> ' .q.1� ° ��__ $ -F . XPN Book Page Parcel o_a <br /> r t7 ' S IAe oWnship Range Section <br /> ► Ar <br /> ` h La I e t . � ' r WEST <br /> warm Longitude <br /> s h t DEG MIN SEC DEO MIN tiEC. <br /> LOCATION SKETCH ACTIVITY (f) <br /> NORTH NEW WELL <br /> h h <br /> MODIFICATION/REPAIR <br /> s t • ' V ' 6+� DRePen <br /> 223,0'6 X - l Other(Spe 0y) <br /> t f <br /> o .._DESTROY(Deap.4he <br /> t ° Preeedareaeaa Maledale <br /> r r under (WOLOCaICLOG') <br /> ' PLANNED USE(S) <br /> MONITORING <br /> ' WATER SUPPLY <br /> DomeaPo <br /> ,._.. puEllo <br /> r , <br /> r , � • Irduatlnn <br /> t � <br /> Indusirld <br /> 11W WELLt , <br /> r ' THODIC <br /> Soul'" TION PNOTEC <br /> Illustrate ar Describe Distance of Well from Landmarks — OTHER(SPOCIN) <br /> such as Roads,Buildings FancM Ricers elo <br /> ,PLEASE BE ACCURATE&COMPLETE <br /> ORILLlNG <br /> METHOD FLUID <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> r 13EPTH OF STATIC <br /> WATER LEVEL (FI) b DATE MEASURED <br /> t t <br /> ESTIMATED YIELD MM (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hra)TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATY RIAL <br /> FROM SURFACE HOLE TYcrz <br /> FROM SURFACE TYPE <br /> DIA a MATERIALI INTERNAL GAUGE SLOT SIZE CE_ BEIM <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACS <br /> Ft to Ft 5 pnchea) THICKNESS troches) Ft to Ft (TYPEISIZE) <br /> a� D <br /> ! t1z n <br /> t <br /> , r <br /> 1- ATTACHMENTS (4) CERTIFICA'T'ION STATEMENT <br /> - Geologic Log I,the undersigned cerilty that this report Is Camplete anc#4ailfate to the best of my knowledge and belief <br /> _ <br /> Well construcllonDiagranl NAME ' <br /> (PERSON FIRhk OR CDT N) (TyFkO OR P tNLED) <br /> CfAwm <br /> oil �. Geophys[caf LOU(s) T �� /' ` p <br /> SoillWater Chomresl Analyses (� J <br /> ADDRESS MVSTR1E <br /> 01her 17 <br /> A77ACH ADOMONAL INFORMATR]N IF IT EXISTS Signed - <br /> W Sll AUTHORIZED R RE NTA7 aATr S N G 7 CENT NU ER <br /> own 188 REV 7-90 IF ADOITIONAL SPACE 18 NIrEDED, USE NEXT CONSECUTIVELY NUMBERED FORM( <br />