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xz of ; 3 <br /> QUADRUPLICATE STATE OF CALIFORNIA D U E ONLY = DO NOT FILL II <br /> For Loral Requirements% •WELL COMPLETION REPORT I I <br /> Page__of —7 ,r., Refer to Instruction Pamphlet <br /> STATE WELL N0./STATION N0. <br /> Owner's WeiINo. / �' Na. 4277160 ❑ <br /> Date Work Began �" IC;'��Z Ended X7-..1/ �' LATITUDE LONGITUDE <br /> Local Permit Aggency�,r'r ) ✓<' Oi,, r�1 L t t f--1rG t `#1 <br /> Permit No. <br /> C� _ 4 Permit Date ? I l i Z <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) VERTICAL _ HORIZONTAL _ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER—(Ft.) BELOW SURFACE Mailing Address <br /> pT FROM �. I <br /> SURFACE DESCRIPTION - `�4 ' <br /> FL to Ft. Describe material,grain size,color,eta. CITY - WELL LOCATION STATE ZIP <br /> Address <br /> City <br /> County I ' <br /> l <br /> APN Book Page L Parcel <br /> or <br /> Township Range Section <br /> ht-." l or NORTH WEST <br /> Latitude Longitude <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITYO <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> DESTROY(Dosent, <br /> Procedoreaand Materials <br /> Under"GE0L0GICLOG') <br /> in -PLANNED USES) <br /> in <br /> m <br /> MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> Irrigation <br /> Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Spacity) <br /> such as Roads,Buildings,Fences,Ricers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING rl ` ,, ; <br /> METHOD FLUID <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_ (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be represenrative of a well's Jong-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. w MATERIAL/ CE- BEN- <br /> (Inches) 5 DIAMETER OR WALL IF ANY HENT TONITE FILL FILTER PACK <br /> Ft. to Ft. zm w $� d GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> ts <br /> ATTACHMENTS (2! ) CERTIFICATION STATEMENT <br /> �/r• <br /> Geologic Log I,the"ersigned,certify that this report i9'Complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) I.. - - ttI <br /> _ Soil/Water Chemical Analyses I _Y{; i (_. Z j Y i',( <br /> ADDRESS CITY STATE LIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> ELL DRILLER AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NU BER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />