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TRIPLICATE STATE OF CALIFORNIA T Pt 1 -�-- <br /> Owner's Copy WELL COMPLETION REPORT _ STATE WELL No tsrArlaN No <br /> Page_L of__ Refer to Instruction Fampblet ❑ ❑ <br /> Owner s Well No ._ /i.t, I No 554302 <br /> l 1 71 <br /> LATITUDE LONGITUDE <br /> Date VYark Began 1- ' )r' Ended ��� <br /> Local Permit Agency `T f ' PN R , rH <br /> I Permit No `I} Permit Date I-`t `( <br /> FR <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) --.0/6VERTICAL _HORIZONTAL — ANGLE —(SPECIFY) Name V �rR '?•n�—�-j������ <br /> DEPTH TO FIRST WATER ljlell (Ft) BELOW SURFACE Mailing VAddress -- <br /> DEPTH FROM ' <br /> SURFACE DESCRIPTION '^� k� ! ��" �`�� STATEart <br /> P' <br /> Ft to Ft Descrtbe material grain size,color etc WELL LOCATION <br /> t I C1 A �y1 �) Address'z.� t ; r'1 e <br /> L r7 , U City+ r_ I <br /> CountyCf- <br /> 1 ^ ' APN Book ' `Page Parcel <br /> 'a, t'1 t N' ' �' = ^� `-" Township 1 Nj _Ranges Section_IT[ I <br /> Y- <br /> r Latituorde t r NORTH Longitude wEsr <br /> 1 ' I 1 i , Y DEG MIN SEC DEG MIN SEC <br /> 1 LOCATION SKETCHACTIVITY (.!L J <br /> tip'1, NORTH EW WELL <br /> MODIFICATION lREPAIR <br /> + —Other(Specity) <br /> 13 i A.\` 1'' &4 r DESTROY(Describe <br />' 1 , » wI• \.• Y PraLeduraaarid Matensis <br /> glider-GEOLOGIC LOG <br /> PLANNED USE(S) <br /> Lu No <br /> }�-I—) <br /> • - _t - M1 A f, j _ 4 ` N �-atoNrlORI <br /> WA-TER SUPPLY?Dornealt <br /> Puala~ <br /> r <br /> oil <br /> Irrigation <br /> _ ; Industrial <br /> 'TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> ' Illustrate or Describe Distance of WeR from Landmarks - OTHER(Spec,ty) <br /> t such as Roads BuFences Rtoers etc <br /> PLEASE BE ACCildings rEF b COMPLETE <br /> , t - <br /> METHOD <br /> [--r f ,A -G FLUID <br /> WATER LEVELS YIELD CIF COMPLETED WE L <br /> DEPTH OF STATIC <br /> ' WATER LEVEL _(Ft) 3 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.� - (Feet) 'May not be representative of a well's long-term yield <br />' DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE ✓ INTERNAL GAUGE SLOT SIZE FROM SURFACE TYPE <br /> 01A z m MATERIAL/ MENF hICE BTO£N <br /> TE FILL <br /> — DIAMETER OR WALL IF ANY FILTER PACK <br /> (inches) a a o `- GRADE <br /> Ft t0 Ftm H v (inches) THICKNESS (inches) Ft to Ft (TYPEl51ZE) <br /> , <br /> - ATTACHME%TS (!) CERTIFICATION STATEMENT <br /> I the undersigned certify that this report Is Complete and accurate to the best of my knowledge and belief <br /> Geologic Lag <br /> Well CaratruCi,an DI6Ofan, NAME K t <br /> r <br /> (PERSON FIRM OR CORPORATIOM MPED OR PRINTED) <br /> Geophysical Lops) K7� Q <br /> SodlWeter Chemical Analyses i� ! �J <br /> SS CITY STATE LP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> WELL ER/ T I R T IYE DATE SIGNED C 57 LICENSE NU BER I <br /> p\4111(38 RE\ 79U IF ADDITIONAL SPACE IS NEF_DE USE NEXT CONSECUTIVELY NUMBERED FORM <br />