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0JJiZRQPLICATE STATE OF CALIFORNIA DWR Use ONLY — Do NOT FILL IN <br /> F'ar Local Requirements WELL COMPLETION REPORT <br /> Page__Of - Refer to Tnsrruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. U� �� ~ � V No. 427758 <br /> Date Work Began 15` L'a'cy L� , Ended )''— � -- LATITUDE LONGITUDE <br /> Local Permit Agency�'' \)1 r;r„t ). , <br /> Permit No. - -�"- Permit Date ''� )�7 �/ i / <br /> TRSIOTHPA <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) VERTICAL _ HORIZONTAL _ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (FL)BELOW SURFACE Mailing Address - <br /> DEPTH FR <br /> SURFACEM DESCRIPTION <br /> Ftto Ft <br /> . . Describe matgrain lCITY material,gran size,color,etc. <br /> � WELL LOCATION STATE ZIP <br /> Address <br /> City <br /> I <br /> County ... <br /> APN Book--. - Page Parcel <br /> Township Range Section <br /> Latitude I I NORTH Longitude I wesT <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH CTIVITY (�) <br /> NORTH NEW WELL <br /> MODIFICATION(REPAIR <br /> —Deepen <br /> I _Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Meteriala <br /> Und..GEOLOGICLOG") <br /> y i- PLANNED USE(S) <br /> or (!) <br /> 3 W MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> _ Irrigation <br /> Industrial <br /> "TEST WELL <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate m Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,eta <br /> PLEASE BE ACCURATE G COMPLETE. <br /> DRILLING <br /> METHOD V FLUID <br /> WATER LEVEL 8 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_ (Firs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield. <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE (- FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. w c d MATERIAL/ CE- BEN- <br /> Ft. <br /> c DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) GRADE MENT TONITE FILL (TYPE/SIZE) <br /> Ft. to Ft. m v c�i� (Inches) THICKNESS (Inches) Ft. to Ft. <br /> AT CHMENTS (✓) CERTIFICATION STATEMENT <br /> I,the undeeslgped certify that this repo Is compl to and accurate to the best of my knowledgA_NZS1 <br /> . Geologic Log -- <br /> _ Well Construction Diagram NAME / / r <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Loge) ; <br /> _ Soil/Water Chemical Analyses <br /> ADDRESS CITY 7 STATE <br /> Other 11 ;-Signed /ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. WELL DRILLER/AUTHORIZED REPRESENT TIVE DATE SIGNED C5] <br /> DWR 188 REV.740 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />