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ORIGINAL 1,`TATE OF CALIFORNIA <br /> File with DWR WELL COMPLETION REPORT <br /> Page of_ L Rtftr to Initrucrforr Pampblcr STATE WELL NO[STATION NO <br /> Owner's Well No No 421272 <br /> -Date Work Began �- Ended Z y Z uTrruoE LONGITUDE <br /> Local Perit Agencv <br /> Permit o 3 t t <br /> Permit Date � <br /> GEOLOGIC LOG WELL OWNER <br /> 10R:1ENTAT:1ON'�(:_- TRTICAL _ HORIZONTAL —_ ANGLE (SPECIFY) Name <br /> DEPTH FROM H TO FIRST WATER (Ft) BELOW SURFACE Mailing Address 049-Cava,ek"Ise 1/r✓i� �� <br /> SURFACE DESCRIPTION —j U.4 Lu iL / <br /> Ft to Ft Dewnbe material, am rrze color,etc <br /> CITY WELL O C A T I 0 N r STATE ZIP <br /> ..r' <br /> t Address aQ W 9/- ANt !115:3 <br /> S c m 3 TO CXR oN <br /> Countv <br /> rL ' <br /> y S/L-T APN Boob o82 Page Parcel6, <br /> L <br /> 3 '� or <br /> Range Section <br /> or <br /> S4AIDS Latitude NOR Longitude WEsLl -10 In 49r <br /> , <br /> r DEG MIN SEC DEG MIN SEC <br /> r� ;3/� p s LOCATION SKETCH TIVITY C )— <br /> NORTH NEW WELL <br /> i <br /> MODIFICATION[REPAIR <br /> ' Deepen <br /> Other(Specify) I <br /> ...�DESTROY(Describe II' <br /> ' nder GEOLndMal"OGIC LOCI <br /> U )I <br /> PLANIPED USE(S)'�� <br /> iv a fir ) <br /> W _/ MONITORING } <br /> i WATER SUPPLY ' <br /> Public <br /> Irrigation <br /> l i <br /> Industrial <br /> TEST WELL <br /> SOUTH - CATHODIC PROTEC ; <br /> ' Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> ' such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE it COMPLETE <br /> ti <br /> DRILLING `` ,, <br /> METHOD ✓H Q#-dLb k1 S T PI!�(�ULFFLUID <br /> WATER LEVEL (t YIELD OF COMPLETED WE L <br /> DEPTH OF STATI *g <br /> WATER LEVEL E <br /> (Ft) DATE MEASURED Z y Z' <br /> i ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING Q (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 3 r a (Feet) May not be representative of a well' long-term yield <br /> DEPTH BORE CASING(S) DEPTH <br /> MATERIAL <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPE <br /> DIAW d MATERIAL[ INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft (Inches) a GRADE DIAMETER OR WALL IF ANY MENT TCINITE FILL FILTER PACK <br /> m y _ (Inches) THICKNESS (Inches) Ft to Ft (TYPE1StZE) <br /> VC .a <br /> .0 sew 146 <br /> .Q 14 <br /> IT , <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log 1 the undersigned certify that this report Is complete and accurate to the best of my knowledge and belle{ <br /> r <br /> Well Construction Diagram NAME <br /> Geophysical Log(a) <br /> (PERSON FIRM OR C TION) (TYPE OR PRINTED)' <br /> ySellrWet rs!��G�hyismt!calAnalyses �t� <br /> `,/Other 4 CSTI ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> WELL DRILL R HORII REPRU, DATE SIGNED CS? LICENSE NUMBER <br /> DWR188FIEV 79D IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM ?!/ S <br />