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' UNP!L42WL STATE OF CALIFORNIA W A U4E 04LY — t F I N <br /> Fro with DWR�r WELL COMPLETION REPORT 1014 NIOIGLI <br /> Page ! OF, Refer to Irtrtruction Pampbter STATE WELL N0.15TATIO NO. <br /> Owner's Well No. <br /> -� No. 422985 ❑ ❑ <br /> * Date Work Began Z Ended /Z' Z/ LATITUDE LONGITUDE <br /> Locale Permit Agency Llelolvkemool <br /> Permit No. V12 14 7S' Permit Date 47-4 r 11,7 APNITRSiOTHER <br /> GEOLOGIC LOC WELL OWNER l i <br /> ORIENTATION �YEATICAL — HORIZONTAL — ANGLE (SPECIFY) Name s /✓ �+ <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address <br /> DEPTH FROM <br /> SURFACE DESCRIPTION CITY �WELL LOCATION STATE tP <br /> Ft. to Ft. Dercribe material, ain ri:e <br /> t <br /> Address- 2/347 4 +,e Lfl .,f/.9LGT��1 Csi <br /> E t <br /> City rum l.'e—n2 . _ � �SxO f <br /> County S- coldLe UVZ:K <br /> APN Book Pag Parcel <br /> Township Range Section <br /> LatitudeNORTH Longitude t WESr <br /> DEG. MIN. SEC- DEG. MIN. SEC. <br /> LOCATION SKETCH yGcTIVITY (!) <br /> NORTH J <br /> NEW WELL <br /> _ MODIFSCATION/REPAIR <br /> ' .. <br /> a <br /> _Deepen <br /> ^Other(Specify) { <br /> DESTROY duresa dMat <br /> Procedures end Materials, <br /> I Under"GEOLOGIC LOG')' <br /> I- I- PLANX1ED1USE(S)= <br /> W Q ALL// <br /> + W MONtTOAING r. <br /> I i WATER SUPPLY I <br /> Domestic <br /> t Public <br /> Irrigation <br /> 4 Industrial <br /> "TEST WELL., <br /> I <br /> CATHODIC PROTEC- <br /> SOUTH TtON <br /> Illustrate or Describe Distance of Weft from Landmarks — OTHER(Specify) <br /> zr 3, Z such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING TH �," <br /> �C <br /> r i <br /> ME O <br /> D '�-.57+7 f7IJFLUID �Z�- <br /> f � <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC 73 <br /> WATER LEVEL (Ft.) & DATE MEASURED <br />` ESTIMATED YIELD Z_(GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORINC _(rFy-ett)) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL — (Feet) 'Afay not be representative of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH I ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> DIA. x W MATERIAL! CE- 8EN- <br /> o g c <br /> (Inches) a "' x� a DIAMETER OR WALL IF ANY FILTER PACK <br /> o GRADE MENT TONITE FILL <br /> Ft. to Ft. (inches) � THICKNESS (Inches) Ft. to Ft. (TYPElSIZE) <br /> -a C;;ig V1 Z S'i/qp <br /> ZS ✓e Z 5C .a /O <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> •/ I, the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Lop /� <br /> Well Construction Diagram NAME �` <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) I <br /> Ile I <br /> Geophysical Log(s) <br /> Sol/Wafer Chemical Analyses '1 <br /> t�r �e7 rrLe t"aADDRESS L. CITY STATE 11`P <br /> ATTACH ADDITIONAL INFORMATION IF 1T EXISTS. Signed d 07 `� -- <br /> WE LL AUTHORIZED RE SE ATIVE DATE NE C-51 LICEN5£ NUMBER <br /> DWR 188 REV.790 IF ADDITIONAL SPACE I NEI: D, USE NEXT CONSECUTIVELY NUMBE�RRED FORM <br />