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ORIGINAL STATE OF CALIFORNIA Y I <br /> File with DWR WELL COMPLETION REPORT <br /> pagE_L of Refer to Irestruerran Pamphlet <br /> STATE WELL NO/STATION NO <br /> Owner's Well No MW- 1 No4 212 9 5 t f <br /> Date Work Began^/��I��9.:t Ended LAn*� LONGITUDE <br /> Local Permit Agency v <br /> Permit No �.�3_ � '3 Permit Datc XV L l <br /> GEOLOGIC LOC /WELL OWNER <br /> ORIENTATION (r VERTICAL — HORIZONTAL — ANGLE —(SPECIFY) Name � "' , <br /> DEPTH FROM DEPTH TO FIRST WATER,2-2—(Ft) BELOW SURFACE Mailing Address S s- <br /> SURFACE DESCRIPTION f <br /> Ft to Ft De mbe material, airs size color,etc CITY STATE ZIP <br /> WELL LOCATION <br /> D : d .S 5 At- Address D t� <br /> (gr5 1 •! s +-T ML Cit} TDC <br /> L Count} <br /> dF <br /> APN Bool.& J age 3 Parcel��r� — <br /> Township 42241 Range e6-=ESection <br /> Lak or N�TM Longitude wFsT <br /> DEG MIN SEC DEG MIN SEC <br /> ' LOCATION SKETCH ACTIVITY {�) <br /> ' NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> i Despen <br /> Other(Specify) <br /> .r DESTROY(Describe <br /> Procedures mad Materiels <br /> ' Under GEOLOGICLOG 7 <br /> PLANNED USES) <br /> � tu MONITORING <br /> i <br /> i WATER SUPPLY <br /> ._,... Domestic _ <br /> Public <br /> irrigation <br /> i <br /> Industrial <br /> T TEST WELL <br /> CATI-MIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from,Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rluers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> ILLING <br /> MRETHOD _ 140[_1-PJW S7 JFK- FLUID <br /> WATER LEVEL 6 YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL Z_, (Ft) h DATE MEASURED irk. <br /> ESTIMATED YIELD` (GPM) 3 TEST TYPE <br /> TOTAL DEPTH OF BORING r_(Feet) TEST LENGTH (Kra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 3�+.0 (Feet) May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORETYPE r FROM SURFACE TYPE <br /> HOLE —w INTERNAL GAUGE SLOT SIZEDIA CE BEN <br /> finches) K W d MATERIAL! DIAMETER OR WALL IF ANY MENT Tl)NITE FILL FILTER PACK <br /> Ft to Ft y GRADE (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> (Z_ (1L J <br /> :/9.5 7 <br /> " C_ I' 5CH go <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I the undersigned Certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geologic Log (/ �/��.��// <br /> _.,_ Well Construction Diagram NAME ^yl 'e� �Y t�yt� _ — <br /> (PER FIRM OR CDRFqpON) (TYPED OR PRINTED) <br /> Geophysical Log(a) <br /> II/Water Chemical Ane ease <br /> zo <br /> LnCJ�TI Z HAP � STATE ZIP <br /> Other ��/O <br /> ATTACH ADDRrONAL lNFORMATIQfY IF IT EXISTS Signed <br /> YYEL4LL&E1/AQ1T %Di1iELt1A111&""_ DATE SIGNED C 5] LICENSE iRlo <br /> DWRIHaItEV 700 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM �" <br />