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ORhlNAL 41Tt11.1ffi1FLL11Y �- 311AIE110110 07 F ! N <br /> STATE OF CALIFORNIA <br /> File with mh WELL COMPLETION REPORT C <br /> Page of� Refer to InrtrttesroPnyPra�rap/,hloe�t r� n <br /> Owner's Well lYp - �� f�a L� G G t^) G G LJ <br /> n LATETtlO13 tONGlruDa <br /> Date Work Began nded <br /> Local Permit Agency SA it n+ Lull— • tiJ �✓1"[Px•✓I ti{ .7'Aly� <br /> Permit No. Peanut Date Nt S/o R <br /> GEOLOGIC LOG = f "n, uSw ti 6. <br /> y WELL OWNER <br /> ORIENTATION (✓) VERTICAL —1#014Z014TAL —ANGLE —(SPECIFY) Nar[le' � �+)'`a �fV• <br /> DEPTH TO FIM WATBA n)BELOW SURFACE Mailing Addreks 0_ <br /> �SURFArE D>;SCIiIPIION d1' 48 <br /> `G! D. <br /> �Ft <br /> Derenbe matenal, am.nze,color,etc ti,ti Cn! ` a { STATE ZIP <br /> WELL LQ ATION <br /> El.ddrem, <br /> Seitzf City f'I " 1444 lYTC0 v], <br /> County <br /> i )PN Book Page Parcel <br /> r r I 1 OF <br /> To';Wflp�� _Range section 0 <br /> r , e _ a > ar <br /> Latitu r I NORTH Longitude I r- WEST <br /> 01 CO, MIN, SEC DEG• M1M SEC <br /> —LOCATIONNORTHSKETCH GTI VITT <br /> NEW WEEL <br /> MODEFICATIONIREPAIR <br /> ' - ��+'�' r•+Lr/� Despea <br /> _Other(specify) <br /> DESTROY(Descrlba <br /> , i Frocaderea®adMaesrrela <br /> antler GEOLOGICLOG) <br /> PLANNED USE(S) <br /> m <br /> ' ' J 3 Git- MONITORING <br /> i WATER SUPPLY <br /> r i <br /> r <br /> �,..,. <br /> Domestic <br /> r <br /> Peb6e <br /> lsrtafr <br /> fnduslrfal <br /> _- "TEST WELL <br /> — CATHODIC PROTEC <br /> r , SOUTH TION <br /> Illustrate or Describe Distance of Well from landmarks OTHFR(Specify) <br /> ouch as Roads Buildings,Fenees Ricers etc <br /> PYXASE BE ACCURATE& COMPLEM <br /> r r <br /> DRILLING <br /> METHOD • t7fC� `� FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> r DEPTH OF STATIC p� <br /> WATER LEVEL (Ft) S DATE MEASURED <br /> a 1 <br /> ����'�yy ESTIMATED YIELD* (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING^�r.S(Feet) TEST LENGTH (lire) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL�_(Feet) "May not be repretentatrue of a weth brig-term yreld <br /> DEPTH CASING(S) OEM ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE r FROM SURFACE YYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA r W a 4 MATERIALI CE BEN <br /> (inches) F d GRADE <br /> OR WALL 1F ANY MENT TONITE FILL Fil TEA PACK <br /> Ft t0 rnt FE rn a (Nitres) THICKNESS (Inches) FL to Ft_ ( : ) (f) (4) (TYPt=!SIZE) <br /> 0 :1171. vc, '51"/ C "Vo <br /> ' a7. <br /> r f r <br /> , r <br /> r ' <br /> ATTACIiIrIENTS (✓) CERTIFICATION) STATEMENT <br /> I,the undersigned, ertI that this report Is comk ate and accurate to the best of my knowledge and belief <br /> � <br /> ZCae'aglc Log Welt Conetructfon Dlearans IYARfE <br /> t3eophYelcal Ca0(a) <br /> (PERSON FIRM cit OORPORAIWN)(TYPED OR PRIMED) <br /> --, � . ,� n <br /> Sail/Water Chemical Analyses r—nt <br /> atter. ► ADDRESS tr SIAM t1P <br /> h-7 C111 <br /> ATTACH ADD1170MAL INFORMATICW tP IT EXISTS Srpaed f <br /> NlELL Fat AUTHORIZED REFRESENTATNE DATE IGtfED FSI UOENSE NUM ER 71 <br /> DWR188REV 7 g IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />