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OF l AL STATE OF CALIFORNIA ` - F I I — � <br /> e with DW WELL COMPLETION REPORT RID 19 01 1 <br /> Page of <br /> Refer io Instruction PemPhlet STATE WELL NO-1STAn0 ANO. <br /> y [I ❑ <br /> I Owner's Well No. Nc. 422984 <br /> I Date Work Began !Z L� Ended LATITUDE LONGITUDE <br /> I �~ Local Permit Agency <br /> �} Permit No. �0/&7 -7-457- Permit Date Z <br /> GEOLOGIC LOG WELL OWNER <br /> i ORIENTATION (z�) _ VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name yaRr OF K / ) I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE -Mailing Address <br /> DEPTH FROM - - <br /> + SURFACE DESCRIPTIONCIn STATE ZIP <br /> { Ft. to Ft. Describe material,grain rize,color,ew. WELL LOCATION <br /> {•� Address ..Z/aD <br /> `City <br /> County <br /> 19 <br /> d <br /> APN Beak Page Parcelof <br /> J' Township Range Section i <br /> + or <br /> Latitude_ NaAm Longitude t west ' <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH CTIvITY (�} <br /> NORTH NEW WELL <br /> MODIFICATION REPAIR <br /> _Deepen <br /> i <br /> _Other(Specify) ! <br /> i <br /> S <br /> - DESTROY(Describe <br /> Procedures i J aMaterials <br /> Under"GEOLOGICLOG") <br /> 7 <br /> - PLA I ED USES) <br /> LU MONITORING <br /> WATER SUPPLY <br /> !v <br /> - Domestic � <br /> Public <br /> r irrigation <br /> Industrial <br /> "TEST WELL" <br /> 1 SOUTH��� GATHOOIC PROTEC- <br /> TION <br /> I!lustr¢te or Describe Distance of Well from Landmarks OTHER(Specify) <br /> �� // <br /> such as Roads,Buildings,Fences,Ricers,etc. <br /> PLEASE BE ACCURATE 6 COMPLETE. <br /> DRILLING ' <br /> ' <br /> METHOD�Le-vly .'7y4L-_gq(,LUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL ---� <br /> DEPTH OF STATIC <br /> WATER LEVEL STATIC// <br /> WATER (Ft.) & DATE MEASURED Z i <br /> ESTIMATED YIELD 1 _�(GPM) & TEST TYPE I <br /> TOTAL DEPTH OF BORING 2 Z's (Feet) TEST LENGTH Mrs.) TOTAL DRAWDOWN (Ft.) I <br /> t <br /> TOTAL DEPTH OF COMPLETED WELL _Z1_010 (Feet) `May not be representative of a well's long-term yield. I <br /> 1 <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> EIORE- <br /> FROM SURFACE HOLE TYP7�2 <br /> FROM SURFACE TYPE <br /> DIA. c w MATERIAL! INTERNAL GAUGE SLOT SIZE CE- SEN-z DIAMETER OR WALL IF ANY FILTER PACK <br /> i)nchas) ` GRADE MEENT TONITE FILL Ft. to Ft. m (inches) THICKNESS (inches) Ft. to Ft. (TYPE/SIZE) I <br /> 0 /v P✓C Z- eSuf SSD O <br /> p <br /> � I <br /> TTACHMENTS (zL) CERTIFICATION STATEMENT <br /> I <br /> Geologic Loo t,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief, 1, <br /> , <br /> `t• _ Well Construction Diagram NAME ���� �'a'� �:iJ�• `���� L� ��C.. '^'��u�✓�W' � ' <br /> (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses" <br /> /r1A1 ADDRESS CITY STATLr ZIP <br /> 21,01her _3!r— <br /> ATTACH ADRIPONAL WFORMATION. IF IT EXISTS. <br /> Signed IEL LER THO ED PR TATIVE DAi SIGNED C-57 LICENSE NUMBER <br /> DWR ISSREV,;-BO IF ADDITIONAL SPACE t EDED, USE EXTQONSECUTIVELY NUMBERED FORM OGa`�i <br /> a� <br /> C` E <br />