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ORIGINAL STATE OF CALIFORNIA <br /> File with DWR WELL COMPLETION REPORT <br /> 5 <br /> Page�of Reler ro Instruction Pamyhlct STATE WELL NO/STATION'NO <br /> Owner s Well No Z No 554301 <br /> LATITUDE LONGITUDE <br /> Date Work Regan )~nd <br /> Local Permit Agency N LOCAL �F-Fttitfccl� <br /> . Permit No�sy� — _ Permit Date 2 <br /> IGEOLOGIC LOC WEL OWNER <br /> ORIENTATION (!) VERTICAL _ HORIZONTAL _ ANGLE — (SPECIFY) Name 1� r <br /> DEPTH TO FIRSf 1hATFR�(Ft) RELnw SLRFACE Ma)hng Address ` <br /> DEPTH FROM R TTT1 G <br /> SURFACE D E S C R I P ION Sib LT_ <br /> I Ft to Ft Descnhe material grain size color etc CITY STATE ZIP <br /> �c� � WE L ATlo� <br /> Lac <br /> f L r Cit} <br /> ' 3 5 - APN Soot. -7Page _ Parcel <br /> f F TOw nship. J� Range�!=Section N f <br /> 3 Latitude L I NORTH Longitude _ wesT <br />' DEG MIN SEC DEG MIM SEC <br /> LOCATION SKETCHT�VITY (!) <br /> tML3 ► NORTH ✓ rt>rw WELL <br /> L <br /> MODIFICATION/REPAIR <br /> L.- CL-A. L' Deepen <br /> Other(Specify) <br /> d LA <br /> 44 <br /> t s� .►� G <br /> , <br /> —DESTROY{Deacn6e <br /> fLa.l�l t.+�i 4P_P_ <br /> Procedures and Mererieis <br /> 7 under GEOLOGICLOG174 , L� L 1� tMDL 'r- v � PLANNED USE(S)l rwONiTORING <br /> , <br /> WATER SUPPLY <br /> G/n1 <br /> lY — Domestic <br /> Public <br /> Irrigation <br /> Industrial <br /> TEST WELL <br /> ' CATHODIC PROTEC <br /> SCUTT I TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Sueldengs Fences Rivers etc <br /> PLEASE BE ACCURATE U COMPLETE <br />' DRILLINGI! �r��� <br /> METHOD � �S.a+�.srw FLUID <br /> WATER L VEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATI <br /> WATER LEVEL ;t*O (Ft) A DATE MEASURED <br /> a <br />' J � 1 ESTIMATED YIELD' (GPM) & TEST TYPE IP <br /> TOTAL DEPTH OF BORING SSL(Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> DIA ,t W W MATERIAL/ CE BEN(Inches) _� a DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to Ft y e�i� GRADE (inches) THICKNESS (Inches) Ft to Ft MENT TQNlTf FILL (TYPEISIZE) <br /> (✓ ) (✓ ) {✓ ) <br /> 1 0 <br /> ?+. cH LIp � 3 <br /> lie ,L o2 3 clt�� <br /> 1 f <br />' ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> — Geologic Loa I the undersigned certify that this report Is Complete andaccurateto the best of my knowledge and belief <br /> Well Construction Diagram NAME LZ 1 Aj <br /> e i r F&—Lz>ex,> t f - --- - <br /> ( RSON FIRM OR CI)MRATION) (TYPED OR PRINTED) <br /> Geophy Log(s) <br /> Soil!Waterlar GMmlcel wnalyeen <br /> Other <br /> ADDRESS CITY / STATE 'ZIP <br /> � <br /> ATTACH A0Dt710NAL INFORMATION IF IT EXISTS-1 <br /> f S Signed !� <br /> WELL LE D'REPRESENTATIVE OA7E STGNEQ C57 LICENSE NUMBER <br /> DWR108REV 790 IF ADDITIONAL, SPACE IS NEEDS SE NEXT CONSECUTIVELY NUMBERED FORM I�ow f(I <br />