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4Q$LGWAL STATE OF CALIFORNIA R U nT Fii <br /> File with DWR WELL COMPLETION REPORT ot <br /> Pae of-3— Refer to lnrrruction P,am filet STATION NO. <br /> Owner's Well No. No. n 7 p <br /> fate Work Began A I Z R,3_, Ended 3 T F 1603 LATITUDE LONGITUDE ❑ <br /> I_ Local Permit Agency tiJ [+ il�. �.r,.T .,.. .rr�� Q,�� <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION ( ! ) VERTICAL _ HORIZONTAL � ANGLE _ (SPECIFY) Name m u D — S Tom' C�•r7' <br /> DEPTH FRuEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address- ?5 �1 5r f Irk -'/b�✓ <br /> OM <br /> �. <br /> SURFACE DESCRIPTION ca 4-1A-4 <br /> Ft, to Ft. Dercnbe material,gram ti7C,color,etc. CITY STATE ZIP <br /> 0 ; � WELL LOCATION <br /> sV^j Sr address J Q'n!I L.3 . Y�A-I PJ Sr. <br /> City <br /> =j r S L Aft i.0 i — County SA a�QLt.," <br /> ' r <br /> A PN Book f4 �Pageo Ste' Parcel"7 7a7_ <br /> w' or <br /> r+ Township aly Range Section <br /> or <br /> G7 /� Latitude I I, NORTH Longitude � I � wesr <br /> 5 � 1 I r7 L.H � - ✓ca wN Sr; flEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH i AIZTIVITY ( ) <br /> G ; NORTH T NEW WELL <br /> A y��7� M�AEM ST' MODIFICATION)REPAIR <br /> c —Deepen <br /> .3, I-rV CLAy 08 . v c - f _other(Specify) <br /> ia V DESTROY(Describe <br /> Procedures and Materials <br /> i Gtlr Under"GEOLOGIC LOG") <br /> LT r .� N , �yy�, T- F Atm b PLAN) ED USES) <br /> MQ a GD' w (') <br /> jMONITORING <br /> 4 � WATER SUPPLY <br /> �f 7 <br /> y E <br /> 15, �L > J'J \ � LT r.4\ F�✓M •r �OD � Domestic <br /> T ' EF+ �..� _ Public <br /> _ Irrigation <br /> Industrial <br /> Z Z .Lr SA-_4f .TEST WELL.. <br /> t N N!�! ' +� B s _...., CATHODIC PROTEC- <br /> ✓� SOUTH TION <br /> ZA I(lustrale Or Describe Distance of Wel!from Landmarks — OTHER(Specify) <br /> such ua-Roads,Buildings.Fencer,Rivers,etc. <br /> PLEASE BE ACCURATE tT COMPLETE- <br /> -4 <br /> OMPLETE- <br /> 4 DRILLING f 1 /J r\QUt iJ <br /> i METHOD !0 ; -ZP f6A-- FLUID <br /> tn\e. WATER LE 'EL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC Q fJ �/ <br /> WATER LEVEL_ �� .mil (Ft.) & DATE MEASURED 1 1� l <br /> LESTIMATED YIELD <br /> /� NA (GPM) & TEST TYPE AN4 <br /> 4 <br /> TOTAL DEPTH OF BORING 2(' (Feet) TEST LENGTH) (Hra.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *Afay not be representati e of a well'i long-term yield. <br /> DEPTH CASI NGS) ❑EPTH ANNULAR MATERIAL <br /> BORE- <br /> FROM SURFACE FROM SURFACE TYPE <br /> HOLE TYPE i <br /> DIA. P w MATERIAL/ INTERNAL GAUGE SLOT SIZE C�- 9EN- <br /> o DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) a o a GRADE MENT TONITE FILL ) <br /> Ft, to Ft. m y 3; <br /> µ (Inches) THICKNESS (Inches) Ft- to FL (TYPF!SIZE) <br /> G 51h 10 — <br /> �Z .S .+art 1 <br /> 1 <br /> ATTACHMENTS { L) CERTIFICATION STATEMENT <br /> [AAE_M,�. <br /> dersigned,certify hat this report is complete and ac�lrate to the hest of my knowledge and belief. <br /> 1 Geologic Lag Well Construction Diagram arul v n1ERSON, FI OR CO PORATi N) ( ED ORP NTE) <br /> Geophyaical Log(s)_ Sail fWater Chemical Analyses CI(Y STATE ZIP i <br /> Other - -q�L.., <br /> ATTACH ADO7710NAL INFORMATION. IF IT EXISTS. Signed. & La <br /> WELL GRILL At17HORI R DATE SIGNED.+�J CSJ it E3 BER- <br /> 1 DWIIMREV-7-Do IF ADDITIONAL SPACE IS NEEDED, U$ NEXT GONS ELY NUMBERED FORM <br /> >> ' <br />