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ORIGINAL STATE OI CALIFORNIA I <br /> File with DWR WELL COMPLETION REPORT <br /> Page Of_L_ Refcr to Instruction Pampblet STATE WELL NO ISTATION NO <br /> Ouner's Wel! No No 554302 <br /> I Date Work Regan�Llg I�`� Ended LATITUDE LONGfTUDE <br /> Local Permit Acncr L,,.. �— i <br /> Permit No Permit Date <br /> GEOLOGIC LOG KFI L OiiNER C <br /> ORIENTATION (! _ZVERTiCAL — HORIZON�T���AALiiL�,, ANGLE (SPECIFY) Name <br /> DEPTH p <br /> DEPTH TO FIRST 'AATER�{Ft) RFLnw SUFFACE Mailing Address - � t r <br /> sORFDES CRIPTI0NT b <br /> FI to Describe mwenal grmn size color etr CI Y <br /> STATE ZIP <br /> " ELL LOCATION <br /> (QAjIi] `ti` Address <br /> i4 tL � Gity T' <br /> tti V C �+le tE7 Fs4£ tA�a Count,, ;444 7 <br /> APN Acnic age Parcel �� <br /> ' L A3 n rt^ _F <br /> � �I <br /> yy mtJl�� To�onslilp-��1�Range - Section <br /> ' G4� -01 V I Latitude NORTH _ <br /> �� L_ DEG M1N S£C �'aUEr'itllf�P--DEG t MIN ' SEG WEST <br /> Tc LOCATION SKETCH A� VITY (� <br /> j W t�t <br /> NORTH NEW <br /> WELL <br /> J <br /> MODIFICATION!REPAIR <br /> 3 F! I <br /> Deeper, <br /> N <br /> _ n <br /> T_'6 44 fkY� �- —.Other(Specify) <br /> DESTROY(Descnbe <br /> G)iN� ^ Procedures and Materiels <br /> 5 ( I l,1ILS1� Under GEOLOGICLOG) <br /> -PLANNED USE(S)- <br /> I is w <br /> I Ma1JITpRING <br /> t <br /> I � WATER SUPPLY <br /> Domestic <br /> 1� tit Public <br /> N <br /> 1 <br /> irrigation <br /> IndustrialIndustrial <br /> 6FF,z,:S _ TEST WELL <br /> i CATHODIC PROTEC <br /> SDUTH TION <br /> Illustrate or Describe Durance of Well from Landmarks OTHER(Specify) <br /> such as Roads Butldtngs Fences Revere etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING t r <br />' METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLET D V%'E L <br /> DEPTH OF STAT! <br /> WATER LEVEL �f- b 6(Ft) & DATE MEASURES) <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL ` (Feet) *May not be represemaime of a;velli long-term yield <br /> DEPTH CASING($) ANNULAR MATERIAL <br /> BORE DEPTH <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPE <br /> DIA z rr MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> (inches) c o� GRADE DIAMETER OR WALL IF ANY CE REN <br /> Ft to Ft MENTTONITE FILL FILTER PACK <br /> u4 (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> C 171, SCH KO 3 <br /> 0 02 3 >✓t5 <br /> I , <br /> ATTACHMENTS (4l CERTIFICATION STATEMENT <br /> GOOIC9IC Lop I the undersigned cert f that this report Is completeand accurate to the best of my knowledge and belief <br /> Well Conaiructlon Diagram NAME E I'T1J1^v <br />' (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> GeoPhyter Chemical <br /> � IZT L� �` _ _ ��J � � 9- <br /> SoIIlWaterChem7calAnalysaa �C�f E-iC,�-4v <br /> ADDRESS <br /> Other CITY / l�STATE C^ �]rZIfP/ <br /> AlTACN ADDITIONAL INFORMATION IF IT EXISTS Signed 61 ! - 7 J l,.r LY�CJ <br /> WELL LER ORIZEO REPRESEtiTATNE DATE MNED C57 LICENSE NUMBER <br /> DWR 188 REV 7 90 IF ADDITIONAL SPACE IS NEEDS USE NEXT CONSECUTIVELY NUMSEREO FORM )�� <br />