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' ORIGINAL STATE OF CALIFORNIAw N — N <br /> File with D� WELL COMPLETION REPORTS <br /> Page—Lof Refer to Insrrvelron Pampblef STATE WELL NO f 9TATrOIT NO <br /> Owner s Well No f 2 NO <br /> 554301 <br /> Date Wort( Regan Frid LATITUDE LONGITUDE <br /> iLoral Pernut Agency O p A <br /> Permit No?SLI Permit Date.312j4 <br /> GEOLOGIC LOCWEL OWNER <br /> I CIA <br /> ORIENTATION (:L ` VERTICAL _ HORIZONTAL _ ANGLE _ (SPECIFY) Name � L <br /> CS <br /> DEPTH TO FTRCT u ATFR 1/ (Ft 1 R£Lnw %RFACE Mailing Address ` 7 11 <br /> DEPTH FROM + <br /> SURFACE D E S C R I P I o n S Z77 dS t nr G ���� <br /> Ft to Fi Descnbe masenal gram irze color etc CITY" STATE ZIP <br /> �5'Ei�L LI ATTO,�� <br /> Address . icf G i s'°1.h.1 S�C2f~r <br /> I^ Counts ,f <br /> 3 5 <br /> i- 4- APN Soo/, t �� Page= Parcel <br /> I F Tow+nship–! !� Range Sectioor <br /> n N f <br /> 3 Latitude NOR- Longitude <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH A&MVITY (!) <br /> IMLJ LY+_ NORTH _V NEW WELL <br /> L 1 MODIFICATION t REPAIR <br /> V e JA rqj L 4.4A.4 l5Deepen <br /> _Other(Soecity) <br /> 4 <br /> Ljam t, ( f <br /> DESTROY(Dand <br /> d Mat <br /> Underribe <br /> ProceGEOL dMaterG <br /> Under GEOLOGfC LOG) <br /> 114 �, l�l� G }1 N1JJt G t Ip s PLANNED USE(S) <br /> P r 3U:1 <br /> A 'y ONITORiNG <br /> WATER SUPPLY <br /> lU Domestic <br /> �,.,... Public <br /> f I Irrigation <br /> Industrial <br /> - TEST WELL <br /> _ CATHODIC PROTEC <br /> SOUTH TION <br /> Illtestraie or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buddings Fences Rivers etc <br /> PLEASE BE ACCURATE 1r COMPLETE <br /> DRILLING t t q <br />' <br /> METHOD 1% FLUID <br /> WATER L VEL h YIELD OF COMPLETED WELL <br /> DEPTH OF STATIt, �J 4 <br /> WATER LEVEL �� (Ft) b DATE MEASURED Li [. <br /> ESTIMATED YIELD' (GPM) d TEST TYPE <br />' TOTAL DEPTH OF BORING In C//(Feet),,,,�,_, TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 2 *C (Feet) 'May hot be representative of a well'y long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE SORE fnc <br /> ,r FROM SURFACE TYPE <br /> HOLEINTERNAL GAUGE SLOT SIZE <br /> D)A MATERIAL/ DIAMETER OR WALL IF ANY CE BEN <br /> (Inches) a� GRADE MENT TGNITE FILL FILTER PACK <br /> Ft to Ft (Inches) THICKNESS (Inches) Ft to Fi (TYPEISIZE) <br />' d � (�) Imo) (�} <br /> ?" cN Ll C.2 : -35 <br /> 02 cl�a�7 <br /> (� Z12S�t1 � <br />' ATTACHMENTS CERTIFICATION STATEMENT <br /> f the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well <br /> Construction Diagram <br /> — GeLog K L e I IBJ FEI_z)GyZ t N C <br /> �._ onNAMF <br /> Geophysical Loo(s) <br /> '] (PERSON FIRM OR CURPORATIONN)) (TYPED DR PRINTED) r,/ /`-�-� // (S'�� <br /> Soil/Water Chemical Analyses <br /> Other <br /> ADDRESS GTl' STATE ZIP <br /> „— _ <br /> ATTACH ADDITIONAL wFOR#AtiTi0W OF IT EXISTS Signed <br />' WELL bMLE p-REPRESENTATIVE DATE SIGNED E57—LICENSE NUMBER <br /> DWR 188REV 7 90 IF ADDITIONAL SPACE IS NEE=D£ SE NEXT CONSECUTIVELY NUMBERED FORM <br />