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• ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL I <br /> File With DWR WELL COMPLETION REPOR9 I I I I I I I I <br /> Page of L (�—� j/Yt a—s 91— Refer to Instruction Parnpblet STATE WELL NO/STATION NO <br /> Owner's Well'NO 1�Eg fhr6L U-j/ No <br /> 559870 <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No Permit Date J APWT <br /> GEOLOGIC LOG _ WELL OWNER <br /> ORIENTATION (✓} _ VERTICAL _ HORIZONTAL _ ANGLE _ (SPECIFY) Name <br /> DEPTH FROM DEPTH TO FIRST WATER (Ft) BELOW SURFACE t" ling A dress <br /> SURFACE DESCRIPTION `" ''" ,`) 1 <br /> Ft to Ft Desenbe material,grain size,color,etc CITY Y STATE ZIP <br /> WELL LOC TION <br /> Address' <br /> City _ <br /> County. J=zx <br /> APNr Book pageParcel <br /> o <br /> Township Range Section <br /> Or <br /> Latitude I I NORTH LongitudeWEST <br /> ' DEG MIN SEC DEG_ MIN SEC <br /> Q LOCATION SKETCH ��prCTIVITY <br /> NORTH �i NEW WELL jt6,9r/ <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> Other(Specify) <br /> 9 r } - <br /> �G�e S <br /> c` <br /> —DESTROY(Describe <br /> Procei <br /> t , Under dGEOLOGures and MCLOGt) <br /> t s I t- PLANNED USE(S) <br /> W r/ f i <br /> m �4 <br /> MONITORING <br /> i <br /> WATER SUPPLY <br /> i <br /> — Domestic <br /> i <br /> — Public <br /> irripahon <br /> e <br /> — Industrial <br /> i <br /> ' _ TEST WELL <br /> i <br /> — CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such us Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE u COMPI ETE <br /> DRILLING QjV'S•T42'1} <br /> ' METHOD—_._ T /'LVID <br /> WATER LEVEL & YIF'LD Of COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well s long-term yreld <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE _ FROM SURFACE TYPE <br /> DIA m z o¢ d MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (inches) c z o� GRADE DIAMETER OR WALL IF ANY MFILTER PACK <br /> FE to Ft ENT TDNITE FILL <br /> m N coo W O (TYPE/SIZEuches) THICKNESS (Inches) Ft to Ft (✓ ) (� } (� ) ) <br /> It Im I IRF <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> the undersigned certify that t Is report Is complete an accura to the best of my knowledge and belief <br /> Geologic Log i <br /> Well Construction Diagram NAM <br /> Geophysical Log(a) <br /> .,SON FIRM OR-CORPORATION) (TYPED OR PRINTED) <br /> /.! <br /> — <br /> Soil/Water Chemical Analyses �„j,/aQ1` t- 14A <br /> ADDRESS• <br /> —CITY <br /> Other CIN STATE ZIP <br /> ATTACH AADlT10NAL INFORMATION IF IT EXISTS Signed <br /> WELL ORILLEA AUTHORIZED REP ENTATIVE DA SIGNED C57 LICENSE NUMBER <br /> DWR 158 REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NE CONSECUTIVELY NUMBERED FORM <br />