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TRIPLICATE STATE OF CALIFORNIA w sl N Y — N I F I N <br /> O.wner's-Copy ----- WELL COMPLETION REPORT - -- J <br /> Page of_ Refer to Instructton Pampblel STATE WELL NO(STATION NO <br /> Owner's Well No _; No 425684 C <br /> Date Wort, Began Ended LATITUDE LONGITUDE <br /> Local Permit Agencv Pik - _. �� � I I L_ _I I I I I <br /> PermiLNFo Permit Date APN/TR I TH R <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION {z} r VERTICAL — HORIZONTAL — ANGLE _ (SPECIFY) Name lam` ty Qf <br /> DEPTH FDEPTH TO FIRST WATER (FL) BELOW SURFACE Malting Address-- .f��11135� dw <br /> ROM <br /> SURFACE DESCRIPTION clr� �- - <br /> Ft to Ft Describe material ain size,color etc . ST zIP <br /> WELL LOCATION <br /> Address <br /> 367 Tq sand City <br /> I <br /> County <br /> -499 412 sand a mu -xapie3 APN Boot Page Parcel <br /> Township Range Section <br /> or <br /> Latitude_ NORTH Longitude t WEST <br /> DEG MIN SEG DEG MIN SEC <br /> 454 4W QlaY LOCATION SKETCH ACTIVITY998 {!)— <br /> ' NORTH — NEW WELL <br /> MODIFICATION/REPAIR <br /> =M clay, Mau Deepen <br /> — Other(Specity) <br /> , I <br /> DESTROY(Describe <br /> Procedures and Maienals <br /> Under GEOLO&CLOG <br /> PLANNED L)SE(S) <br /> W <br /> 3 w ( • ) <br /> MONITORING <br /> 594 607 am-6 0—m-13 gravel WATER SUPPLY <br /> , I <br /> — Domestic <br /> PuWIC <br /> - Irnpatron <br /> I <br /> Industrial <br /> I <br /> — TEST WELL <br /> SOUTH TON ODIC PROTEC <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as goods Rivers eti; <br /> PLEASE BE ACCURASTEences& COMPLETE <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> I I <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD <br /> (GPM) 8 TEST TYPE � <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'Mav not be represemauve of a well's long-term reld <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL � <br /> FROM SURFACE GORE TYPE ' FROM SURFACE <br /> HOLE {— TYPE I <br /> INTERNAL GAUGE SLOT SIZE <br /> (Inches) <br /> DIA W MATERIAL/ CE BEN <br /> a o o GRADE DIAMETER OR WALL 1F ANY MENT TONUE FILL FILTER PACK <br /> Ft to Ft m J (Inches) THICKNESS (Inches) Ft to Ft / (TYPEiSIZE) <br /> // <br /> W l I) ( ) ( ) <br /> , <br /> n 1/ <br /> (� -4 11 <br /> 354 3-n 1 S7 <br /> 1 <br /> I <br /> p <br /> 4D4 4M1 I li <br /> dc:An 11[} n <br /> ATTACHMENTS (.::L) CERTIFICATION STATEMENT <br /> — Geoiog,c Lag 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 /> — Geophysical Log(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> SOII/Water Chemical Analyses <br /> — Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONA4. INFORMATION IF IT EXISTS Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C 57�LICENSE NOMBER <br /> Davit 184REV 7 90 IF ADDJTIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />