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RIGINAL SPATE OF CALIFORNIA w U§F ON — QQ ac _F <br /> File W1W:DWA Y WELL COMPLETION REPORT 0 <br /> vage�Of—F— Refer t0 Inrtruction Pamphirt STATE WELL NO/STATION NO <br /> Owner's Well No �1[>t.i .� No 422421 ❑ ❑ <br /> Date Work Began Ended LATITLE15 LOXGJIrUDE <br /> Local Permit Agency Lt+ � � f d' t� �21/`I�r <br /> P 3 OTHE <br /> Permit Na Permit Date � <br /> GEOLOGIC LOG W,ET.,,L OWNER <br /> ORIENTATION (✓] }�VERTICAL —HONUONTAL —ANaLE —(SPECIFY) Nartte <br /> DEFM TO FIRST'WATER (FL)BELOW Soma Mad?n&' ddgess <br /> 'A;`11&4$i(t J .c., l—At,� <br /> DEPTH FROM0../ <br /> sURFAC>: DESCRIPTION ��, ` 1'!'1 - - <br /> Ft to Ft Dascrtbe m rerral ,grain st7e Color,eta � CITY I � ' WELL L Q C AT I O N TATE ZIP <br /> Address' <br /> ' ALCity' s a <br /> t , Y9C'OUDty� <br /> 1 , _ � � 'S J <br /> D&Gki AP iBook Paged Parcel <br /> 'oYwphi� 7^'/�l1 Range .Section <br /> ` Iatitude_ Nin! Longitude W � <br /> DER. MIN SEG DER. MRL SEG- <br /> ~ LOCATION SKETCH TIVITY (✓) <br /> r ,r `N • NORTH ?wWELL <br /> htbDIFIGATOHIREPAlp <br /> i ♦ i a _ { S ` {per I Deepen <br /> ' t ! L ! �3 �i� P �,•�i,( �.Other(SpoaNY) <br /> 610�'w�'� DE97RbY(nBlaff69 <br /> , t' �, Y 1i Pmcrdrrea ertQAlalorials <br /> GEOLOMCLOG1 77 <br /> J <br /> t– PLANNED USES) <br /> t (—') <br /> KIM <br /> WATER SUPPLY <br /> , <br /> � r <br /> DemesOa <br /> ' Pubue <br /> e ' IrapeUoa <br /> , <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> I t SOUTH TIO(q <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Sgaaty) <br /> such as Aaads Suddinga Fencer Hiaem rte <br /> PLEASE BE ACCURATE& COMPLETEL <br /> i r <br /> DRILLING <br /> McTHOD MTif few -Vt'el r1 J? FLUID <br /> i WATER LEVEL & YIFLD OF COMPLETED WELL <br /> r DEPTH OF STATIC_ '34,10 c <br /> WATEA LEVEL— (Ft) d DATE MEASUREB <br /> i t <br /> ESTI)AATEiD YIELD (G¢)N) dt TEST TYPE <br /> TOTAL DEPTH OF BORING Fee TEST LENGTH "a)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL, +1 (Feet) 'May not be repreteurnuve of a uell s tong-term y+eld. <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ! FROM SURFACE TYPE <br /> OUL z MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inchea) a aRADg DIAMETr;R OR WALL IF ANY MENT TONNE FILL FILTER PACK <br /> Ft to FI Ouches} 7ht(CKNESS (Iachasy Ft to F( (TYPEfSIZE) <br /> 9.S' o kiPUS r D ,fad 27 .2r <br /> t <br /> 1+ --t ---t-- <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> Geologic Log 1,the undersigned,certify that this report is eckm tete and accurate to the best of my knowledge and belief <br /> Well Conairoctian Diagram NAME <br /> (POISON FLW nR W TON) PFD OR FRIti7ED) <br /> Geophyalcal Log(e) I> ` <br /> Sad/Water Chemical Anglysea ricl <br /> Oiher it _ A� CISY STATt ZIP <br /> ATTACH ADDITIONALiNFORFAATlQN !F 1T$X13T$ Signed `' <br /> WFLL DRILLER ALRHCRIIE6 REFRFSENFA7NE DALE SIGNED C37 LICENSE NUMBER <br /> DWRI"RFV 790 1F ADDITIONAL SPACE IS NEVDED, USE NEXT CONSECUTIVELY NUMBERED FORM t M-1-1 <br /> � � l <br /> %Nlif'}���d f ^/ <br />