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t ORIGINAL STATE OF CALIFORNIA5 <br /> Y — <br /> File with DWR WELL COMPLETION REPORT <br /> Page Of` Refer to Initi urttort Parrtpblet STATE NO TSTA IOn NO <br /> Owner s Well No - NO 554306 111 1 1 1 1 ::11-1 <br /> Date Wnrl. Began S Ended <br /> LATITUDE LONGITUDE <br /> Local Permit A enc, tic 114 <br /> Permit No S y -+- ,Permit Date APNiTp r R <br /> I EOLOGIC LOC .}. WE OWN_}E_R <br /> ORIENTATION (!} VERTICAL ^ HORIZONTA/�`L��`` ANGLE _ (SPECIFY) Name + <br /> DEPTH TO FIRST 4t 4TER�C _]___1Ft s BELOW SURFACE Mailing address <br /> DEPTH FROM S <br /> SURFACE DESCRIPTION <br /> Ft to Ft Derrnhe mCITY aterral gram size color,etc V4 EL=ATION STATE ZIP <br /> i` Address 3 f LT <br /> l LT (.1t) c <br /> o- Ls t Counts <br /> —xLIr AGfC rti A P N P.k Page _ Parcel0� <br /> r Township Rangel—IC Sectionof <br /> (n <br /> N 5.L Al LAoj Latitude NORTH Longitude I WEST <br /> ff <br /> DEG MIN SEC DEG MN SEC <br /> LOCATION SKETCH AC11VITYJQ fes} <br /> f i NORTH -L_It�EW WELL <br /> r tMODIFICATION I REPAIR <br /> 1 ' . v t IRS— <br /> RS .�.Deepen <br /> Other(Specify) <br /> r n-f A5 mak, --�, <br /> S Ro D DESTROY(Describe <br /> } Procedures ertd Matenefs <br /> V� Under GEOLOGICLOG) <br /> Cf�k I- PLAN�'EIyLSE(S) <br /> 0 <br /> yLU <br /> LU MONITORING <br /> v� <br /> �! WATER SUPPLY <br /> _ <br /> Domestic <br /> i r <br /> U <br /> Public <br /> I — T Irrr9ehon <br /> (�L(.,� Industnat <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rroers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> � METHOD_�_ � YJ� FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATI03 <br /> WATER LEVEL (Ft) & DATE MEASURED <br />' ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft 7 <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) `May not be representattze of a well's long-term)acid <br />' DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE .1 FROM SURFACE TYPE <br /> DIA e W d MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft (Inches) V �? J GRADE Dl(intch s) THICKNESS CKNESS ER OR WALL IF ANY(n hes) Ft to Ft MENT BN FILL FILTER PACK <br /> m (TYPE/SIZE) <br /> ` 2 C <br /> 3 IQ oZ 1, �5 <br />' 2 2 i <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> Geologic Log I the and rsigned certify that this report Is complete <br /> and accurate to the best of my knowledge and belief <br /> ] � j� <br /> Well Construction Diagram NAME � "`Y� <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) T �/��/� �) -� <br /> Salllwater Chemical Anayaeo 2-4&1-G �" ST�' "tJ C— <br /> ADDRESS CITY STATE ZIP <br /> Other t" � � <br />' ATTACH ADDITIONAL. tNFORAfAT70/J 1F IT EXISTS Signe <br /> WELL ER D AT DATE SIG ED C 51 LICENSE NUMBER <br /> DWR 188 REV 7 90 IF ADDITIONAL SPACE IS NEEDS , USE NEXT CONSECUTIVELY NUMBERED FORM /C t7 <br />