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ORIGINAL STATE OH CALIFORNIAOW Y — <br /> ' <br /> Fie with DWR WELL COMPLETION REPORT <br /> PageOE / Refer io Instru,tian PJmphlet STA WELL NO lSTA7iON NO <br /> Owner s Well No ` �/ 445599, . ❑ <br /> Date Werk Began — Ended / , LATITUDE LONGITUDE <br /> ocil Permit Agency 1 �1 <br /> Permit No 00 1472167 Permit Date /—Z7_"J N,TFIr <br /> GEOLOGIC LOG '^ WELL OWNFR <br /> ORIENTATION (!) — VERTICAL — HORIZONTAL _ ANGLE _(SPECIFY) Name r zC_ <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Nla ng Add �057 OOZE d= <br /> DEPTH FROM <br /> SURFACE DESCRIPTION v <br /> Ft to Ft Describe marenal grain size color etc CITY STATE ZIP <br /> WEj �LOCAT��V <br /> Address //YY�� 77 <br /> City i pen - - - - - <br /> County7W 0- <br /> r l <br /> ' LPN Book Page�� ! arcel <br /> Township QZZZD Rang ectlon r <br /> LatitudeNORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH TIVITY (L) <br /> NORTH NEW WELL <br /> , <br /> ' MODIFICATION i REPAIR <br /> �� _Deepen <br /> Other(Sgacity) <br /> L 19lel DESTROY(Describe <br /> Procedures endAd Materiels <br /> Under GEOLOGICLOG) <br /> y PLAN, D U5E(S) <br /> W a (✓ ) <br /> 7i Lu MONITORING <br /> i <br /> A7ER SUPPLY <br /> i <br /> Domestic <br /> j Public <br /> T, rmgstion <br /> Industrial <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 Ricers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> GRILLING <br /> ' METHOD � " ' vFLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-terns yield <br /> ' DEPTH SCE CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT S)IE <br /> (IDI s) ,c wad MATERIAL! DIAMETER OR WALL IF ANY CE BEN <br /> Q o _ GRADE MINT TONITE FILL FILTER PACK <br /> Ft to Ft m c+a (Inches) THICKNESS (inches) Ft t0 Ft 1 (TYPE/SIZE) <br /> ) (!) fes) <br /> TTACH,NENTS (!) CERTIFICATION ST%TEME, T <br /> I the Sign earthhat thus report I Com to a.Dq,ac u e t the best of my knowledge and belief <br /> Geologic Log J- IJ// <br /> Well Construction Oiagram NAM <br /> (PERS FiFIRM OR CDRPORAIIDN) ivrpio 59 PRINTED) <br /> GeaphYsital 1.09(a) <br /> SadlWater Chemical Analysea C / <br /> ADDRESS CITY STATE ZIP <br /> Ocher ILATTACH ADDITIONAL INFORMATION IF ITEXISTS SignedLL DRIL R AUTH D REPO NTATIVE OA IC 57 LICENSE NUMBER <br /> DDI►18nkibv 'w IF ADDITIONAL SPACE IS NEEDED NEX CONSECUTIVELY NUMBERED FORM <br /> 1 �? <br />