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QUADRUPLICATE STATE OF CALIFORNIA D W R LSE ONLY - DO N O.T FILL I N <br /> 1 For Local Re irennents WELL COMPLETION REPORT STATE WELL NO.ISTATION He <br /> Page�of� �� <br /> P y Refer to Intnuc/ion Pamphlet <br /> No. F== E 11 <br /> Owner's Well No. t 21 O 1 �) � LATITUDE LONGITUDE <br /> Date Work Began Ended 554352 <br /> Local Permit Aency <br /> AP /TRS/ TH <br /> Permit Noa"_cx) 1: /—a';1 Perm- Date 'Ln 12.r626Z <br /> GEOLOGIC LOG r WELL, OWN <br /> VERTICAL _HORIZONTAL ANGLE (SPECIFY) Name <br /> �J <br /> ORIENTATION (—) y J�..t I <br /> DEPTH TO FIRST W.ATERZM <br /> Ft.) BELOW SURFACE arin A rens '. <br /> DEPTH FROM �P re <br /> SURFACE DESCRIPTION clry STATE ZIP <br /> Ft. to Ft. Dererihe material,grain rim,color.etc. W E L C,, O C A T 19 N <br /> Address IA�( N E <br /> City � "C 14—f _, <br /> County fJ ti Ut' Cx i A L 1lJ <br /> APNBook Page Parcel <br /> Towenship Range Section <br /> - Q' Latitude g WEST <br /> ( j NORTH Longitude <br /> (t t N l 0 Q t+ [�o DEG. MIN. SEC. DEG. MIN. SEG. <br /> ! LOCATION SKETCH (iL)- <br /> 71 <br /> NORTH t _NEW WELL <br /> to }.,� {/fir�+(A < - y f1-,J� 'V 1 -f( MODIFICATION/REPAIR <br /> 71 �� 12 _Deepen <br /> it I I+V"e <br /> DESTROY(Describe <br /> Proacohmesend Materials <br /> Untler"GEOLOGICLOG'') <br /> F P1 V v <br /> `, y N PLANNED USE(S) <br /> rn <br /> m W W MONITORING <br /> L` <br /> WATER SUPPLY <br /> `— Domestic <br /> 1- <br /> _ PUEIic <br /> Irrigation <br /> In hif,tdel <br /> "TEST WELL" <br /> CATHODIC PROTEO- <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 <br /> METHOD UID <br /> WATER LEVEL & Yf O COMPLETED WELL <br /> DEPTH OF STATIC <br /> t <br /> WATER LEVEL (FE) & TE I ASURED <br /> ESTIMATED YIELD" (OP & TESJf"4"'„S'E <br /> TOTAL DEPTH OF PORING (Feet) TEST LENGTH (HrsJ TOT DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May Not be representative of a well'r long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- TYPE FROM SURFACE. TYPE <br /> HOLE (� <br /> DIA. MATERI NAL GAUGE SLOT SIZE CE- BEN <br /> (Inches? — DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. Ouches) THICKNESS (Inches) Ft. to Ft (TYPE/SIZE) <br /> [ 7 .l 7 <br /> ATTACHMENTS (z CERTIFICATION STATEMENT— <br /> I,the undersigned,COT Ity th�11 is/.report is,ynmplete and a urate to the best of my know <br /> Jgdge an�belief. <br /> Geologic.Log+ 4_`c I 1 1'JG. Y p <br /> _ Wall Co Loo <br /> agram NAME ) � <br /> V L (PERSON, FIRM, 0,5„CORPOMTION) (TYPED OR PRINTED) <br /> { ^✓�^� / �T �.. <br /> — Geophy i.t ( ` `l /� tA I< 1 (..t �GL-L_-/ �7rZr�L/J l A 7 S?t� <br /> Spill Wat he Analyses <br /> ADDRESS CITY SAME ZIP <br /> Dthat d3 <br /> ATTACH ADDED0 AL INFORMATION. IF IT EXISTS. Signed <br /> WELL E U E ATIV "l. DA E SIGNED GB] LICENSE NUMBER <br /> DWB 188 REV.v-go IF ADDITIONAL SPACE IS NEEDde, USE NEXT CONSECUTIVELY NUMBERED FORM <br />