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ORIGINAL STATE OE CALIFORNIA � Y I <br /> File with DWR WELL COMPLETION REPORT <br /> Page Of_L_ Refer ro Instruction Pamphlet STAIT WELL N )STATION NO <br /> Owner s Well No _��,}_'' _ j No 554302 <br /> Date Wort. Began'11�g Iy1 _ Ended ���$�I-4 LATITUDE ElLONGrUOE <br /> Local Permit � encs <br /> (.,OCA. Z1 <br /> Permit No Permit Date Pi I`t <br /> GEOLOGIC LOC A F I L Ov%NER <br /> ORIENTATION (4} VERTICAL — HORIZONTAL ANGLE — (SPECIFY) Name ` <br /> DEPTH FROM DEPTH TO FIRST WATER. i iL (Ft) RFLO%k SURFACE Mailing Address - 5- <br /> SURFACE <br /> SURFACE DESCRIPTION' <br /> Ft to Ft Describe mwerui! C: Y STATE ZIP <br /> grmn s::.e color err " ELL LOCATION <br /> (DAiroi Lri C Address <br /> A . =� Cit) T c <br /> 1 V C ee FI £ '(Al Counth 14 <br /> APN Book age1177 Parcel <br /> N rt<15of <br /> ' r <br /> Tow nslltp ` Range Sectionor <br /> er <br />' 1664LA42 Ke -M y 'e.. t �I�T(� Latitude _30 s t NORTH <br /> Longitude I t WEST�r DEG MIN SEC DEG MIN SEC <br /> - LOCATION SKETCH A� VITY {f) <br /> trJ Y �C <br /> NORTH NEW WELL <br /> J MODIFICATION/REPAIR <br /> ' r —Deepen <br /> Ir A� <br /> 14 —Omer(Specify) <br /> 1 <br /> `N DESTROY(Describe <br /> Ql'r1�1 l "I" p Procedures and Alaterials <br /> L � L � r w � r �`/� !✓-� Under GEQLOG)CLOG) <br /> PLANNED LSE(S) <br /> 044 w a <br /> u' L M ( I } <br /> arelroRlNc <br /> t <br /> � WATER SUPPLY <br /> t µw- , Domesi,c <br /> ', tq.r Public <br />' � Ri Irrigahan <br /> Industriaa <br /> , <br /> 6��ZIG 7 TEST WELL <br /> — CATHODIC PROTEc <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks THER(Spec,ty) <br /> such as Roads Buildings Fences Ravers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING i t <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLET D WE L <br /> DEPTH OF STAT/ <br /> WATER LEVEL (Ft 7 DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hr5) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 'May not be representative of a,Dell s long-term yield <br />' DEPTH CASINC(S) ANNULAR MATERIAL <br /> FROM SURFACE BORE DEPTHHOLE TYPE FROM SURFACE TYPE <br /> DIA a e MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> DIAMETER OR WALL IF ANY CE BE <br /> Ft to FE (Inches) U GRADE MENT TONITE FELL FILTER PACK <br /> H e (Inches) THICKNESS (inches) F[ to Ft (TYPE/SIZE) <br /> 3 2 Izs <br /> ATTACHMENTS (!} CERTIFICATION STATEMENT <br /> — Geologic Lots 1 the Undersigned Certlf that this report Is Completes and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME `-e I J� �(� 1 <br /> Geophysical 1.01)(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> �. �'{ Q <br /> Soil/Water Chemical Analyses + - 1� J 1 WF�J 0 A �� J <br /> 011iADDRESS CITY STATE ZIP <br /> // <br /> er <br /> ATTACH ADDiTTONAL fNFORAfAT10N IF IT EXISTS Signed 7 <br /> (p <br /> WELL LER ORVED REPRESENTATIVE DATE SIGNED C57 LKENSE NUMBER <br /> DW8168REV 790 IF ADDJTIONAL SPACE Ie NEEDE USE NEXT CONSECUTIVELY NUMBERED FORM <br />