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ORIGINAL STATE OF CALIFORNIA WR N Y O N O T F I IN <br /> File With DWR WELL COMPLETION REPORT 172Z f <br /> STATE WELL NOJSTATION NO. <br /> Pa,ue�oF� l;rfcrrulnstn�rtiortY.trrtphlet ElOwner's Well No. No. 3 3 3 49 <br /> Date Work Begand Ended <br /> SID T LATITUDE LONGITUDE <br /> Local Perrnit Agency tell k" r / <br /> Perrnit No, 6y�J�SZ- Permit Bate s A Nrr r R <br /> ' 1 }(/J GEOLOGIC LOG WELL OWNER_ _ _( <br /> DRiENTA t n_r (�) _,L _ VERTICAL HORIZONTAL ANGLE (SPECIFY) Nanle wV <br /> r DEPTH TO FIRST WATER (FL) BELOW SURFACE Ntailing Ade ess <br /> 0, Box <br /> DEPTH FROM SURFACE DESCRIPTION <br /> Ft. to Ft. , Describe material,grain fire,color,etc. CITY WELL QCSTATE ZIP <br /> ATION <br /> Address / stn <br /> Citv <br /> County <br /> APN Book /Y? Page Parcel <br /> Q �►n-P^'r'� T,worship Range Section <br /> or <br /> 1 Latitude i I NORTH Longitude WEST <br /> ' r DEG. MIN. SEC. DEG. MIN. SEC. <br /> to dV` CATIO <br /> L LON SKETCH ACTIVITY {') <br /> NORTH NEW WELL <br /> r <br /> MODIFICATIO W REPAIR <br /> s <br /> i 1 <br /> _Deepen <br /> ' •- ` s 4 ��y ,�j� —Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USE(S) <br /> w af') <br /> 1 LU � MONITORING <br /> ' r 4 N WATER SUPPLY <br /> r <br /> Domestic <br /> r Lai`7 <br /> ..,_,., Public' <br /> r <br /> Irrigation <br /> "TEST WELL.. <br /> t ' `Ju/ TION IG PROTEC <br /> BOUT TION <br /> Illustrate or Describe Distance of Well from Zartdrnaks ___ OTHER(Speeity) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE G COMPLETE. <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> ' TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)JOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's long-terns yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE ✓ FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE _ <br /> DIA. z a �� a MATERIAL/ DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> (Inches) z W GRADE MENT TONITE FILL <br /> Ft. to Ft. �, can (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> (ZL) (''! (—' ! <br /> ATTACHMENTS (.t:) CERTIFICATION STATEMENT <br /> Geologic Log <br /> 1,the undersigned,cert; that this report is complete and accurate to the best of my knowledge and belief. <br /> I Well Construction Diagram 14AME <br /> (PERS N, FI OR CORPORATION) (TYPED L�PRINTED) �f <br /> Gecphyaicel Log(s) <br /> � n r,� <br /> _,_..• <br /> so at Chemical Analyses 5 ✓l /IJrCJi� /l�rw[//'y <br /> ADD—ESS CITY STATE ZIP <br /> Other 5/`O � <br /> ArTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed_.., __ �c•t J <br /> ' WELL AILL111AAUTIlEffilihPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR198REV.7-W) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />