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ORIGINAL STATE OF CALIFORNIA N Y — D 0 NOT 1 <br /> 'le with DWR I 0 0 M <br /> l-.. "JELL COMPLETION REPORT I-r I N I I <br /> ^, <br /> ?'a'ge—t—OE / Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Owners Well ND. No. 464930 ❑ I ❑ <br /> Date Work Began , Ended <br /> LATITUDE LONGITUDE <br /> Local Permit Agency :5igm, 6al4 aM Co &bite kwifi 1wil ctr <br /> r <br /> � Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) _1k_1 VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Name 0/ <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address 0�3 <br /> D SURFACE <br /> PTH M DESCRIPTION �GVI-Ct (A 1 /ht ?yS.2q <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ZIP <br /> � 1 II D {OWUk Bit, 50r <br /> N'ELL LOCAT ON <br /> Address v b Blvd, <br /> City <br /> I� D14, 1 SIO P1� 11V 5 County .Sig .T02�f? <br /> APN Rook Page Parcel <br /> aD i °r <br /> Township Range Section <br /> or <br /> Latitude i NORTH Longitude i WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> _Other(Specify) <br /> 2W�9 DESTROY(Describe <br /> 7 Procedures and Materiels <br /> C[ Under"GEOLOGIC LOG') <br /> N N PLANNED USE(S) <br /> wa (�) <br /> 3 w L_ MONITORING <br /> S / Y <br /> WATER SUPPLY <br /> C 315 Domestic <br /> • Public <br /> Irrigation <br /> Industrial <br /> CO(.�v�1Yy G'tAlb BIVQ _ "TEST WELL" <br /> J CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING y/d <br /> METHOD �II FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELLDEPTH p <br /> OF S LE ELATIC3f /b (Ft.) a DATE MEASURED 6—�� `7 <br /> WATER <br /> ESTIMATED YIELD' (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING ��(Feet) FEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL --:2,Q- (Feet) ',May not he representative of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- ITY@(_� FROM SURFACE TYPE <br /> HOLE <br /> DIA. INTERNAL GAUGE SLOT SIZEMATERIAL/ CE- BEN- <br /> (Incnes) DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MENT TONITE FILL <br /> Ft. tv Ft. (Inches) THICKNESS (inches) Ft. to Ft. (TYPEISIZE) <br /> n .5 q0 o <br /> CIO_ Y c- 4 0 0 OX0 <br /> .a )r raw <br /> It <br /> r--- 4TTACHMENTS (t) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accur a to the b st of my knowledge and belief. <br /> Geologic Log <br /> Well Construction Diagram NAME ��u� / `+� -(PERSON. FIRM, OR CORPORA <br /> ON (TYPED OR PRINTED) �/�/�/��/� /Nye 4 <br /> Geophysical Log(s) P, 0. /.ox a 6+ ? Sem a,a "'t' �I 9�/ 7Z <br /> Soil/Water Chemical Analyses l/ �l <br /> ADDRESS {�s1IL1 �/)1�/ �' CITY /V1yw/ I/� STATE ZIP <br /> ATTACH 4DD <br /> Other <br /> INFORMATION. IF IT EXISTS. Signed ' cL�+� •' '- _1 <br /> WEIL d1RIlLCRiAUTHORIZ[EVREPRESCNTAIIA DATE SIGNED C57 LICENSE NUMBER <br /> ughIhsIuF\ -90 IF ADDITIONAL SPACE IS NEEDED, USEINEXT CONSECUTIVELY NUMBERED FORM 5 <br />