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OatNA� STATE OF CALIFORNIA — F l — <br /> File with DWR WELL COMPLETION REPORT <br /> L� Page Of f] Refer to Instruction Pamphlet STATE WELL NO.!$ AT1ON NO. <br /> Owner's Well No. 3No 471604 17 0 <br /> Date Work Began QI Ended LATRUOE LONGITUDE <br /> 4 Local Permit Agency � wwr Cd ENJ,��0a T <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) VERTICAL _HORIZONTAL _ ANGLE _(SPECIFY) Name V - ST4C v; �e�T I <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address 3-1!5 T y /Do <br /> DEPTH FROM <br /> SURFACE DESCRIPTION 0AWA-4 <br /> Ft. to Ft. I Describe matenal,grain Stu,color,etc. CITY STATE ZIP I <br /> WELL LQCATION I 3 <br /> ars V8 Address j$4?4 - W i ,.Ma+AJ_Sr I I <br /> r <br /> 'City <br /> i ; . ; .1. rCounty .v O �A-d <br /> =r Y APNBook�Page Parcel Q� <br /> Township �- Range 655' Section <br /> S f� ✓e N r. or <br /> ' 1 ` J LatltUde DEG. ` MIN. I SEC. NORTH Longitude DEG. MIN. ' SEC. WEST <br /> lle/A LOCATION SFETGH ,1�LTIVITY {✓J <br /> ia! r+` ✓} NORTH V <br /> .,_, NEW WELL <br /> MODIFICATIONlREPAIR <br /> Deepen <br /> Other(Specify) <br /> 24 ,^.1.4 S,jr Q�„/ r /� ; DESTROY(Describe <br /> 1 1p Procedures end hiWeriats <br /> SO-Ar -r Under"GEOLOGIC LOG'; <br /> 1 PLANNED USE(S) <br /> i Lu (=) <br /> 3 MONITORING <br /> f as WATER SUPPLY I ) <br /> (. I rA +r• Domestic I i <br /> I (,tJt <br /> Public <br /> t <br /> 7_25,2 <br /> S Irrigation <br /> `'� 1• ' SA- ! -o • Industrial <br /> ' oele+_j r , /♦ ..TEST WELL" <br /> Ad a a Mm Tb _ CATHODIC PROTEC- <br /> W O T' SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildings,Fences.Ricers,etc. <br /> ! PLE21SE BE ACCURATE d: COMPLETE. <br /> e� S I' Gl r DRILLING N <br /> METHOD O� - }Vi TTS FLUID <br /> WATER L VEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> ! WATER LEVEL i 2 y2� (Ft.) S GATE MEASURED t <br /> ESTIMATED YIELD*�^(GPM) & TEST TYPE /"l A <br /> 111iiii! TOTAL DEPTH OF BORING (FFe�et)) TEST LENGTH AJAI (His.) TOTAL DRAWDOWN &A (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *.,Nay not be representative of a well's long-term yield. <br /> 1 ' <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE � FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> (InDches) z� a MATERIAL/ DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> Ft. to Ft. ti �� GRADE (inches) THICKNESS MENTTONITE FILL (TYPE/SIZE) <br /> j 1 - M _ (lncnes) Ft, to FL (—) {—) (2L) <br /> _44 <br /> z _P vG Abr1t 3 <br /> ATTACIIMENTS (.L) CERTIFICATION STATEMENT <br /> I, the undersigned,certify that this report is complete and accurate to the b st of my knowledge and belief. <br /> _ Geologic Loc <br /> — Well Construction Diagram NAME� 5 `l k �t�i[ ti-SFr I���} 1 !.�"� /f F. 4"-_ <br /> Geophysical Log(s) <br /> (PER FIRM. OR CORPORATION) (TYPED DR PRINTED) <br /> ,l <br /> Soil/Water Chemical Analyses (��J <br /> Other <br /> CIF! TATE ZIP <br /> ` <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed ^' <br /> l I ) <br /> WELL DRIL EPffrSEN DA Si ED C-5l L ENSE NUMBER <br /> fli.r DWRIHNRFV.--w1 IF ADDITIONAL SPACE IS NEE ED, US EXT CONS ECUTI LY NUMBERED FORM J+� b <br /> ` ` / <br /> J <br />