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ORIGINAL, STATE OF CALIF 11NIA LA2 N Y — N T F r r <br /> File with DwRWELL COMPLETION REPORT r r � <br /> Page' OF Refer to fnfrruerion P.rmphler STATE WELL NO.ISTATION NO. <br /> Owner's Well No. y Z No. 533348 ❑ <br /> 5 O LATITUDE LONGITUDE <br /> Date 1Vaik Began F n(led l <br /> Local Permit Agen if. a !TR ! TR <br /> Permit IVa. Permit Date r <br /> ' GEOLOGIC LOG /1�'f�f W L O1'NER <br /> ORIENTATION / ) VERTICAL — HORIZONTAL ANGLE — (SPECIFY) dame <br /> DEPTH 'ff) FIRST 1V.VTER {Ft.) BELOW SUItEAt:E Ma ing Add ss r Gr 6 <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> ' Deftribe rnaterial,gain file,color, etc CtiY STATE Z]P <br /> Ft. to Ft. W L�LjOCAT1ON <br /> Address s r /�f <br /> Citv <br /> County � <br /> APN Bank hC�_Page - --{�--- Parcel _ <br /> s or <br /> Township lunge Section <br /> or <br /> ' b Latitude I I NORTH Longitude_ WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (:) <br /> NORTH NEW WELL <br /> MODIFICATION I REPAIR <br /> i <br /> � i —Deepen <br /> i / <br /> ' r `6 _Other(Specify) <br /> DESTROY(Describe <br /> `6{ � Procedures and Meferfals <br /> V <br /> Under"GEOLOGIC LOG') <br /> y PLANNED USE(S) <br /> Lu a (—) <br /> W MONITORING <br /> 1 3z.4(/ roe, <br /> wnrEs;SUPPLY <br /> Domestic <br /> Public <br /> ,— Irrigation <br /> / / ._•�• Industrial <br /> yt� <br /> _TEST ST WELL. <br /> CATHODIC PROTEA <br /> � SOU TION <br /> Illustrate or Describe Distance of Well from Landmarks ...._. OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,eic. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING <br /> METHODFLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> r i <br /> ESTIMATED YIELD' n (GPM) & TEST TYPE <br /> i:1 <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH �(Hrs.) TOTAL DRAWDOWN (FtJ <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be reprefentati✓e of a well's long-term)ield. <br /> DEPTH CASING(S) ,M <br /> DEPTH ANNULAR ATERIAL <br /> BORE-' <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA. W MATERIAL/ �EB <br /> (Inches) i w x a DIAMETER OR WALL [F ANY FILTER PACK <br /> Ft. to Ft. GRADE (Inches) THICKNESS (Inches) Ft. to FL MFILL (TYPEISIZE) <br /> ' ATTACHStENTS {!) CERTIFICATION STATEMENT <br /> 1,the undersigned,car 'fy that this re ort is Cpmplete and accurate to the best of my knowledge and belief. <br /> Well 4iC Log 1 ♦ �w <br /> _ <br /> Well Construction Diagram NAME 09 CORPORATION) (TYPED OR RIHTrED) ////JJ !/ <br /> Geophysical Log(s) _--_._ __ VV -T 4,N—we-1, <br /> > . q7sgs <br /> �..` <br /> Soil?Water Chemical Analyses ••J�_ vV r - <br /> ADDRESS CITY STATE ZIP <br /> _. Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Srgned NfEI 'LER AUTHORlZE6 REPRESENTATIVE DATE SIGHE`OD C-57 LICENSE ER <br /> DWI]IM REV.7.90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM / 4C!�� <br />