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9 <br /> N f <br /> DUPLICATE STATE OF CALIFORNIA D W R U E ONLY — DO NOT FILL IN <br /> Driller's Copy WELL COMPLETION REPORT - I I' I I I I„ lI I s <br /> Page_Of Refer ro Instruction Pamphirr STATE WELL NO.ISTATION NO. <br /> Owner's Well NO. No. 4O p r��D E,7717 0 C <br /> Uate y�i'Ork Rcgatt FebE�,nllr�d <br /> Q Q L 8 LATI[UDE LONGITUDE <br /> L,Ocal Perinil ARenc'y 5CIII5 s dt)o1 I l I I I I I I , <br /> Permit No. Permil Dale <br /> (. •. ) o(;IC LOC WF:1,1, 0IVNI?R <br /> ORIENTATION (V) _"VERTICAL _ HORIZONTAL — ANGLE _ (SPECIFY) Name � re e P 110; <br /> DF.PTFI TO F]RS -AAT WATF11 _ I1 t) IIIl' SIIIIPACF. Mailing Address 983 <br /> eo <br /> DEPTH FROM ]11S _ <br /> SURFACE 1)F.SC R I PT I O N <br /> CITY SLATE <br /> Ft. to Ft, Lkreribe material,grain rice,color,crc. WELL LOCATION <br /> Address_ e+c A"if4.44 ea t a r <br /> rz� . <br /> [:ity uirteee <br /> -1-0 11 SendCONnt� 111A A <br /> 11 36 clay AI'N Book Page Parcel <br /> or <br /> I'mVRsllil) Ran);c St-CliOlt <br /> or <br /> ),alitndr' _ NORTH 1,Onpiturl<' + rebs' <br /> 75 ❑Ep- MIN, SEC. DED_ MIN. SEC. <br /> _ LOCATION SKETCH ACTIVITY82 110 elay <br /> NORTH 1f._._ NEW WELL <br /> i10 1 15 SaIld MOD(FICATION/REPAIR <br /> 115 1 Deepen <br /> HO <br /> Other ISpedy)14 . <br /> DESTROY(Describe <br /> 160 167 Sand Procedures and Mstede <br /> 167 175 Clay Under"GEOLOGICLOG <br /> N PLANNED USE(S) <br /> W MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> f � hrlOalloe <br /> i <br /> i <br /> Industrial <br /> ..TEST WELL" <br /> CATHODIC PROTEt I <br /> SOUTH TION <br /> 711asirale or Describe Vistance of Well from Landmarks .,... OTHER(Speckly) <br /> such as Reads,Buddings,Fences,Ricers,etc. <br /> PLEASE BE ACCURATE 6 COMPLETE. <br /> DRILLING <br /> METHODFLUID <br /> WA L 3 YIELD OF COMPL • L — <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) 6 TEST TYPE <br /> TOTAL DEPTH OF BORING 175(Feel) TEST LENGTH (Hra.) TOTAL DRAWDOWN (FT.) <br /> TOTAL DEPTH OF COMPLETED WELL (Fret) "May not be repreremarive of a well'.f long-term yield. <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE i <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> IDIA. MATERIAL/ CE- BEN <br /> (Inches) z W z_ a DIAMETER OR WALL IF ANY FILTER PACK <br /> FI. to FI. x �� J GRADE (inches) THICKNESS (Inches) Ft. In FI. MENT TUNtTE FILL (TYPE/SIZE) <br /> m <br /> ell <br /> 10 <br /> 134 , <br /> I <br /> ATTAC11NIENTS (!) CERTIFICATION STATEMENT <br /> — Geologic Log I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief- <br /> Well Construction Diagram NAME= <br /> (PE I 4R I ) ( 0 3 1 <br /> — Geophysical Log(s) <br /> ,.^,. Soil I WateT Chemical Analysesi <br /> ADDRESS TE <br /> — Other <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS. Signedp <br /> W 1 ®IONLW I G5T R <br /> DwR IB.4nEV.7-g(1 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM , <br />