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ORIGINAL STATE OF CALrFORNIA WR U ONLY O <br /> Pile With DWR WELLCOMPLETION REPORT C <br /> Page T' <br /> �y oF_r2_— Refer to fnrtructtori Pugfitphlct STATE WELL NO/STATION NO <br /> : � <br /> Owner't Well Np �� No G { ❑ ❑ <br /> Date Work Began , End d � LATITUDE LONGITUDE <br /> Local Permit Agency IA., s tfL� <br /> Permit No y U222 Permit DateER <br /> AP s,oTH <br /> 3— <br /> GEOLOGIC LOG 77 WFkL OWNER <br /> _ ��J�f CLS <br /> OAIENTA7TON {✓) _T <br /> DEMI TO FIRST WATEN (Fl)BELOW SUtiFAa Mailing Address <br /> DEPTH FROM 4L f ` E+ i 1� a Q f <br /> SURFACE DESCRIPTION <br /> FI to Ft Describe material,gmin size,calor,etc �` CITY ' { W L I,�0C TION STATE ZIP <br /> eg- <br /> City, <br /> � � s <br /> AP(V Book Page Parcel/1? <br /> 114A,` r +` .� Tgji sivp.A_Range[ 4 Section <br /> 1 1 <br /> ' Latt�ttide MORT" Longitude_ , wEsr <br /> r 1 +4, y DEG MIN SEC DEO MIN Sac <br /> ' ( LOCATION SKETCH xTVITY (!) <br /> NORTH NEW WELL <br /> MODIFICATION/RERMH <br /> other(specify) <br /> 1 1 V 4t <br /> 1 = 1 <br /> 00 l e- <br /> 1 '1 Vader'GEOLO=Los <br /> i-. PLANNED USE(S) <br /> � ONITORINO <br /> 1 r <br /> , WATER SUPPLY <br /> r 1 <br /> 1 i Domesllc <br /> r Public <br /> irrigation <br /> 40 industrial <br /> T TEST WELL, <br /> 1 1 CATH013LO FROTEC <br /> ' 1 SOUTH TION <br /> r 111ustratir or Describe Vfj G a:a of Weff from 1 andmarls —OTHER(t3peaify) <br /> 1 <br /> Such <br /> Roads Sultdings Fences A4,ars etc <br /> PLEASE PR ACCEMATE& COMPLETJ.r. <br /> 1 � <br /> DRILLING f�� � LVID <br /> r i <br /> METHOD. <br /> ' WATER LEVEL & YIELD OI? COMPLETED WELL <br /> r i <br /> 1 , DEPTH OF STAT1 <br /> WATER LEVEE '�" (Ft) d DATE MEASURED <br /> 1 r ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BOILING (Feet) TEST LENGTH (tits) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL.-�_(Feet) f May riot be reprctCln ime of a well's long-term ytehL <br /> DEaitt <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> BORE <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE 7ypE <br /> DIA <br /> MATERIAL/ INTERNAL GAUGE SLOT SIZE BEN <br /> zW $ q GRADE DIAMETER OR WALL. IF ANY M CENT TONITE FILL FILTER PACK <br /> (Taches U (!) <br /> FAi to Ft e��� pnehes7 CiH1CKNESS {Inaba,) Ft to FS CfYPElS12E) <br /> V 1 1 {! wfLfL)j l <br /> � w <br /> ,F. .aPI/c, <br /> r 1 S7. CL <br /> / <br /> , <br /> ATTACOMENTS (4) CERTIFICATION STATEMENT <br /> i,the undersigned,certify that(his report Is co plate and accurate to the best of my knowledge and ballet <br /> Geologic Lap C <br /> O Wefi Construction Diagram NAME <br /> • (P FIRM 0 CORP9RAMCN (TYPED OR Pli 0) ` <br /> GeapfiysloalLog(s) � �f �t <br /> Soil/Wescal Anelysee tar Chemical i w Y r <br /> Other I�= ADOES <br /> AS IAtY STATE L <br /> ATTACH ADDmoNAL INFORMATION IF tT EXIST& 3,paed �0A S ED GS LICENSE I III <br /> WELL D PR Al1IHORRED REPRESENTATIVE <br /> DWtt188REV 790 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED 7FOR <br />