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QUADRUPLICATE STATE OF CALIFORNIA W R USE ONI Y 00 NOT FILL IN <br /> For Local R utrements WELL COMPLETION REPORT STATE WELL NO/STATION NO <br /> Page OE Refer to Instruction Pamphlet ❑ <br /> Owner's Well No ��r U No 4 +� 1 ❑ <br /> Date Work Began �+� ^rJ{' Ended ' + LATITUDE l 1LONGITUDE <br /> Local Permit Agen y elft' I 11'r, ` �' <br /> Permit No Permit Date��� _ AP <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION �'�l _ VERTICAL _ HORIZONTAL ANGLE —(SPECIFY) Name _ <br /> DEPTH TO FIRST WATER (FI) BELOW SURFACE f Mailing Address f3&Y Y& r <br /> DEPTH FROM t ' 6 ) & 6 '( F"' I <br /> SURFACE DESCRIPTION <br /> Ft to Ft Describe matenal,grain rize,color,etc - s ` CITY WELL LOCATION STATE ZIP <br /> Address <br /> 1ode <br /> City <br /> 'SI( County— 00 <br /> , M11111/11 <br /> APN Book Page Parcel <br /> It 1 ! L Township Range Section <br /> i 4 1RTH I i <br /> ' <br /> Latitude DEG MIN SEC Longitude WEST <br /> DEG MIN SEC <br /> _ LOCATION SKETCH ACTIVITY (✓) <br /> NORTH _ NEW WELL <br /> ' 3r #�'#i '� `16t�'l ►! MODIFICATION/REPAIR <br /> i <br /> Deepen <br /> Other(Specify) <br /> i c <br /> �..,, _DESTROY(bescrfbe <br /> Procedures and Metenets <br /> Under GEOLOGICLOG) <br /> lyy PLANNED USE(S)- <br /> < ( ) <br /> { yt W MONITORING <br /> WATER SUPPLY <br /> 1 1 4 <br /> Domestic <br /> �. <br /> Public <br /> Irrigation <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Revers etc <br /> PLEASE BE ACCURATE & 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 (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be reprerentQttve of a well's long-term yield <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA z x z� a MATERIAL! DIAMETER OR WALL IF ANY CE SEN FILTER PACK <br /> Ft to Ft (Inches) U �? J GRADE (Inches) THICKNESS (Inches) Ft to Ft MENT TDNITE FILL (TYPE/SIZE) <br /> 1 <br /> 1 <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 <br /> (PERSON FIRM OR CORPORATI ) (TYPED OR PRINTED) <br /> Geophysical Log(s) P FF} ^k / 1 <br /> Sod1Water Chemical Analyses i t£ ( ^w. / If _6 I'll }f( ( Ij f '� <br /> Other <br /> ADDRESS / f CITY 1 } �/ /STATE ZIP <br /> �. Signed �r �� �.�C .� � ! I �tI{I� l(i <br /> ATTACf�ADDITIONAL INFORMATION IF!7 EXISTS WELL DRILLER AUTHORIZED REP SENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> DWR t88 REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> A <br />