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ORIGINAL STATE of CALIFORNIA W R U Y -» ❑� NOT F I L I N <br /> ,r File with DWR - WELL COMPLETION REPORT ° ' N ) I L71 ° �j <br /> Pa,' of Refer to InstructionPamphler STATE WELL NO.ISTATION NO. <br /> Owner's Well No. w— No. ' 533350 <br /> LATITUDE LONGITUDE <br /> Date Work Began Ended �G `� <br /> Local Permit Agenc lulo`OV! r TI[ <br /> Permit No. Z Permit Date AP 1H <br /> GEOLOGIC LOC W r7 LL WNER <br /> ORIENTATION (`�} VERTICAL _ HORIZONTAL _ ANGLE _ (SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mail- g Add 55 <br /> DEPTH FROM <br /> ' SURFACE DESCRIPTION Q'�')'t-/Y� <br /> GtTv <br /> Ft. to Ft. Describe material,grain size,color,etc. srATE ZIP <br /> S ELS.fh LOCATION <br /> Address r <br /> Q A 1N1. e+i1 City <br /> tf' County yr <br /> -G N Honk I Page Parcel <br /> �FCA Md� or <br /> uwnship Range Section <br /> A90 LA 10 ff Latitude NORTH Longitude 1 Wass <br /> ' DEG. MIN. SEC. DEG. MIN, SEC- <br /> ; LOCATION SKETCH ACTIVITY (�) <br /> NORTH NEW WELL <br /> MODWICATIONlREPAIR <br /> i V <br /> —Deepen <br /> ' —Other(Specify) <br /> DESTROYProcedure ssndMa erisls <br /> ' l0 I✓ Under"GEOLOGIC LOG' <br /> PLANNED USE(S) <br /> 1 <br /> C MONITORING <br /> WATER SUPPLY <br /> i <br /> 1 <br /> Domestic <br /> Public <br /> Irrigation <br /> Industrial <br /> LA "TEST WELL" <br /> ' 4`�-" • i.! CATHODIC PROTEC- <br /> TION <br /> ROTEGTION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specily) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE t COMPLETE. <br /> DRILLING <br /> 1+AE;npD 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.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) I *May not he representative of a well'r long-term yield. <br /> ' DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA. W d MATERIAL/ DIAMETER OR WALL IF ANY CE- <br /> DIA. <br /> i oc o� GRADE MENT TUNITE FILL FILTER PACK <br /> ' Ft. to Ft. v caq LL (Irtchesl THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> -i (✓} (L) 0:) <br /> ATTACHMENTS (!) 'CERTIFICATION -STATEMENT <br /> Geologic Log <br /> I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. II <br /> Well Construction Diagram NAME ' <br /> (PERSON, F M, OR CORPORATION) (TYPED OR PRINTED) <br /> GeophysicalLog(s) ySf3 ^ ,�� "V <br /> Soil Water Chemical Analyses C/X"nin- <br /> Other <br /> ADDRESS J CITY C / pSTATE ZIP <br /> � E! <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed L�--� <br /> El DRILLER AUTHORIZED REPRESENTATIVE GATE IGNED D `L C57 LICENSE NUMBER <br /> owR Intl REV.T.JD IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />