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ORIMNAL tiIAll Of (AIIIORNIA OWR USE ONLY — DO NOT FILL IN <br /> Fele with DWR WELL COMPLETION REPORT <br /> Page- of Refer ro lnsrrucrron Parnphler STATE WELL NO/STATION NO <br /> r Owncr, Well No No 434197 <br /> ❑ ❑ <br /> I)at( Work Ear gin f 13 d,9 2 Lnd((1 36 q 2 LATITUDE r ONGrTUDE <br /> Loc TI I"crrnit Agency -� L <br /> Pcrinit No .S P(nnft Dat( APNITRS! TH R <br /> C'L,OI OCIC I OC WPI 1 OWN1 R <br /> ORIENTATION {�) T VERTICAL _ HORIZONTAL _ ANGLE _ (SPECIFY) Narne Q _A/CM A5 LL.I N <br /> DEPTH FROM <br /> DFPTH TO FIRST WATER (Ft) BELOW SUIIFACF Mailing Address tt3C3�C 15 Z 12 -- <br /> SURFACE DESCRIPTION ST7]C_'JE'TD/1I !7 c�,_ �'�_ _ <br /> Ft to Ft Dercrrbe material,grain rrze calor etc CITY STATE LIP <br /> WELL LOCATION <br /> C Address 104S G4i—t-1 i C�YA4-775472 6445" <br /> c t t V <br /> County �t7r-r ry(f/,i <br /> APN hoot. Page Parcel <br /> Township Bang( S(etton <br /> or <br /> Latitude DEG I MIN I SEC NORTH Longitude DEG 1 MIM I SEC WEST_ <br /> e <br /> LOCATION SKETCH ACTIVITYO <br /> SS NORTH_� NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> DESTROY(Doscnbs <br /> t <br /> Procedures and Malsnels <br /> ' Under GFOLOGICLOG) <br /> PLANNED USES) <br /> co <br /> Lu ¢ ✓ (�) <br /> to MONITORING <br /> , WATER SUPPLY <br /> Domestic <br /> i a <br /> Public <br /> r ,�,,,_ Irnpalion <br /> , <br /> Oma. r"r=7 to n n <br /> Industrial <br /> Pt L.` U,�u I i WELL <br /> � (1 Urn W <br /> CATHODIC <br /> ODIC PROTEC <br /> SOUTH TION <br /> Illustrate at Describe Distance of Well frorn Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING tn-�77N(hu <br /> PERMIT/SERVI »g METHOD _y24AxW S-o 0j" A061152 <br /> FLUID <br /> WATER LEVEL & YIL.LD OF COMPLETED WELI <br /> DEPTH OF STATIC <br /> WATER LEVEL S (Ft) d DATE MEASURED 0 <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 4-9 —(Feet) IEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May riot be reprererrtarive of a wells long-term yield <br /> DEPTH CASINC(S) ANNUI AR MATERIAL <br /> FROM SURFACE BORE DEPTHHOLE TYPE FROM SURFACE TYPE <br /> DIAY W MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft (Inches) c oz� GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> m H _ (Inches) THICKNESS (inches) Ft to Ft (TYPEISIZE) <br /> 3D ✓ Z SC p O 2 <br /> st-ona Pvc. 1 soy jo o.ozD 2 <br /> 45 ./ L <br /> ATTACHMENTS (.!L) CERTIFICATION STATEMFNT <br />• ✓Geologic Log I the undersigned certify hat this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME '� , 7 <br /> c <br /> Geophysical Log (PERSON FIR RPORAT)ON) (TYPED OR P TED) <br /> Ws) � - <br /> VS0111ater Chemical Analyses c a��17W 9AIC7rH ADDRESS ?% ?I. L A <br /> CITY j STATE zIP <br /> Other <br /> ATTACH ADD(TIONAL INFORMATION IF IT EXISTS Staned <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DAE SIG ED C 57 LICENSE NUMBER <br /> DWH 188 REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />