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ORIGINAL STATE OF CAUVORNIA W Y — g T <br /> Fite with DWR WELL COMPLETION REPORT � <br /> Plage p Refer to fnstrucitan Pamphlet STATE WELL No ISrATION NO <br /> owner's Well No No 422425 ❑ Ele <br /> Date Work Began , Ended c / LATITUDE WNGITWE <br /> Local Permit Agency �'� -d cora. s e <br /> P ITR J <br /> Permit Na Permit 16ate VHER <br /> GEOLOGIC LOG ^ SWELL OWNEII <br /> ORIENTATION (4) VERTICAL —HORIZONTAL ANGLE —(SPECIFY) Name <br /> nePTH FROM DEPTH TO FIRST WATER (Ft) 13ELOW SURFACE M ultng Address <br /> suliFAce DESCRIPTION I ` <br /> FI to Ft l7escrtbe material,gram stzG rola? etc �s`, CRY •� 3 37AT6 DP <br /> WE L ATION <br /> "A. dress: t; L�4�df-4r'C 4 JJ <br /> + ounty <br /> S ^ <br /> 1 .! <br /> AFN Book Page Parcell` <br /> 1 1 ^ <br /> r Tqw slap ' Mange ASG GG Section � — <br /> t titudeDEG MIN 8120. NORTH Longitude <br /> nE4 MIN SEC <br /> LOCATION SXETCH ACTIVITY (!) <br /> �+ NORTHNEW WELL <br /> _ i,� t• <br /> MMIFICA11CMIREPAR <br /> t <br /> .......Oiher(SPacd7r) <br /> c'�. + <br /> _ ` n 1� ,_.DESTROY(pearn6e <br /> Undo GEOLOGIC LOQ y <br /> PLANNED USIE(S) <br /> t � ut MartlTnRlNe <br /> , t <br /> WATER SUPPLY <br /> ` Domostle <br /> s e <br /> PuLita <br /> brlpallp, <br /> t � _� 4tduaUlai <br /> t t ?ESFWEI.L <br /> CATHODIC PROTEC• <br /> t SOUTH TION <br /> Illustrate or Describe Distance of Well from t.andmarkt OTHER(Specity) <br /> such as Roads,Buildings Fences,Rtaen etc. <br /> PLEASE HE ACCURATE& <br /> t COMPLFTP- <br /> DRILLING tD(j f �METHOD– e <br /> A!JPL <br /> VID <br /> i WATER LEVEL S YIELD OF COMPLETED WELL <br /> 1 DEPTH OF STATIC <br /> WATER LEVEL a�'�3 (Ft) 8 DATE MEgSUHED <br /> �-/� ��--- ESTIMATED YIELD' (GPM) &TiEsY TYPE <br /> TOTAI,DEPTH OF BORING_LL'�L_ (Feet) TEST LENGTH "a.)TOTAL I)RAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (feet) a May not be representative of a wet)4 long-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE —TYPE ✓ FROM SURFACE TYPE <br /> DIAm o wg MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft Unch a) n J GRADE DIAMETER OR WALL 1F ANY MENT TONUE FILL FILTER PACK <br /> gad" THICKNESS ftdws) Ft to Ft (TYPEISRE) <br /> o vc- It g140 .oma <br /> , <br /> t , <br /> 1 1 <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENTMO <br /> -- ---�–�--- <br /> \�–G-eologto Log 1,the un erslgn d, eddy that this r pat Is C` tB and accurate to the hest of my knowledge amid belief <br /> 4ti WeR ConslructEon glagtarn NAM) ePEIISSM <br /> FIRM R CO IiAT1nH) (TYPED rl <br /> ...� GeaphYalaal Log(a) <br /> Sag/wales mica,Ana sea /U7 <br /> r �� AgI1RESS cm STALE ZIP <br /> �8ther G, <br /> ATTACH ADoMoNAL MFQRMAVoN W IT EXISTS Signed I <br /> 4tiELL GRkLER AU fill FD REPRESFNTAiIYF l SIGNED G57 LCENS R11MR <br /> DWR tss 119V 7130 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />