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14 <br /> ORIGINAL STATE OF CALIFORNIA N — N T I <br /> File with DWR TELL COMPLETION REPORT 12 o I & INI <br /> Refer to lnstrucsion Pamphlet STATE WELL NO./STATION NO. <br /> Page_L of L_ <br /> Owner's Va'ell No. W No. 464932 11 <br /> Date !Fork Began — 0 Ended G en b l C RA �U`� LATITUDE LONGITUDE <br /> Local Permit Agency <br /> / /OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (�) X_ VERTICAL _HORIZONTAL _ ANGLE _ (SPECIFY) Name of/ <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL LOCATION <br /> L rOUAn 1114y Address CQ1A141fVI'( <br /> City fto <br /> I'/t County �. <br /> ain o (4 111 Co. <br /> APN Book Page Parcel <br /> or <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 4 NEW WELL <br /> a, O cS11*k/ MODIFICATION/REPAIR <br /> _Deepen <br /> ( Still' Cnnar(Specify) <br /> DESTROY(Describe <br /> Procedures and Materiels <br /> Under..GEOLOGIC LOG") <br /> r PLANNED USE(S) <br /> W <br /> a <br /> MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> 'r 1•, �7 Public <br /> ' Irrigation <br /> Industrial <br /> U tk`k, BIN)of _ "TEST WELL.. <br /> ! CATHODIC PROTEC- <br /> SOUTH TION <br /> llluslrale or Desrribe Distance of Well from Landmarks OTHER(Specify) <br /> surh as Roads,Buildings,Fence..s,Rivers,etc. <br /> PLEASE BE ACCURATE t COMPLETE. <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL h YIELD OF COMPLETED N'ELL <br /> DEPTH OLEVEL TIC (Ft.) & DATE MEASURED b-F�_57 <br /> WATEESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING Q (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DFPTH OF COS1PLFTED WELL 140— (Feet) 'A4ay not he represonative of u well's long-teen yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. z o MATERIAL/ CE-FB[ <br /> (inches) DIAMETER OR WALL IF ANY MEN <br /> FILL FILTER PACK <br /> Ft. to Ft. < J GRADE (Inches) THICKNESS (acnes) Ft. to Ft. (TYPE/SIZE) <br /> (2L) <br /> O XI 15tk4o pvc i1 54k go o X <br /> a 010 D X <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Lop +� `►/� ��! ,{/� /�� �/ O/. / <br /> I Well Construction Diagram NAME J � V �-V I r ` <br /> (PERSON, FIRM, OR CO PD A7 N) (TYPED OR PRINTED) <br /> Geophysical Log(s) P. Q. Box a �/7 s��I Vr/r 4 l� <br /> Soil;Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other ,,t-•, <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> W DRILLER/AUTHORI D REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DH H Inti HFs 7110 IF ADDJTIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 10 <br />