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ORIGINAL STATE OF CALIFORNIAN Y hl <br /> File with DWp WELL COMPLETION REPORT 5di- Ajt� <br /> Page. of` Refer to Instruction Pamphler STATE YiEn NO iSTA !ON NO <br /> Owner s Wei <br /> I No No 554306 <br /> LATITUDE LONGITUDE <br /> Date Work Began 3 Ended <br /> Local Permit AenL� tF' «t� <br /> Permit No APNtTR TH <br /> y �" Permit Late <br /> �EOLOC{(' LO(' WE OWNER <br /> ORIENTATION (�) VERTICAL _ HORIZON%L.�� ANGLE (SPECIFY) Mame 1' <br /> DEPTH TO FIRST to ATER4CZ�{Ft I BELOW 5L,RFACE Mailing Address <br /> DEPTH FROM S � <br /> CITY �. <br /> SURFACE DESCRIPTION STATE zip <br /> Ft to Ft Dercrrbe mare,7al groin size color etc V4 ELI, L O C A T I O <br /> �` k3 Address 3 f t_T <br /> t LT City c <br />' t-r t Counri <br /> l, <br /> lL APIv RohPage ar <br /> _ Pcel Q� <br /> 10 t Taw nshep Range C Section Tn <br /> I I- or <br /> LatitudeNORTH Longitude WEST <br /> DEG M!N SEC DEG MIN SEC <br /> LOCATION SKETCH ACPXITY (!I <br /> f A] t _NORTH £w WELL <br /> If <br /> F t MODIFICATION/REPAIR <br /> 3 3 <br /> -Deepen <br /> ( Other(Specify) <br /> I <br /> 37Hof DESTROY fDeacrrbe <br /> i Procedures and Materreis <br /> yy Under GEOLOGICLOG ) <br /> 5t L t'f r-4 �l'�� F PLAN\1E(S) <br /> w L r�� ✓ ) <br /> W MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> V _ <br /> Public <br /> Irr,gation <br /> i <br /> 0, L� Mdvatrra! <br /> TEST WELL <br /> F- CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Desenbe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildrngs Fences Revers etc <br /> PLEASE BE ACCURATE tr COMPLETE <br /> 1 METHOD try +�'M+t2 -> >e/ ( FLUID <br /> WATER LEVEL $ YIELD OF COMPLETED WELL <br /> DEPTH OF S7ATI <br /> WATER LEVEL (Ft) $ DATE MEASURED <br />' ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL.6f,!!C___ (Feet) *May not be representause of a well's long-term yield <br />' DEPTH CASING(S) DEPTH ANNULAR 'MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE "" <br /> 6!A INTERNAL GAUGE SLOT SIZE <br /> tt <br /> x S� MA7EAtAL1 DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> (IncAes7 Q c�, J GRADE MENT TDNITE FILL <br />' Ft to Ft H c o (inches) THICKNESS (inches) Ft to Ft (✓ ) ✓ ) ( ✓ ) (TYPEISIZE) <br /> 3o oZ2 f yr, -! S <br />' ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> I,the andBBBreigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Gell Conogic Loo # '_ J��n ��C <br /> Well Construction Diagram NAME � t` <br /> Geophya4cal Log(a) <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) ' <br /> ._ Soil l Water Chemical Analyses r "LJ <br /> _� Other AOORESS CITY STATE ZIP <br />' ATTACH ADDIT70NAL INFOAMA71ON IF!T E)t7STS sfgn <br /> S1ZZ <br /> WELL ER D AT ATE SIGI C57 LICENSE NUMBER <br /> DWR 188 REV 7 00 IF ADDITIONAL SPACE Is NEEDS , USE NEXT CONSECUTIVELY NUMBERED FORM /5 4 <br />