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QUADRUPLICATE STATE OF CALIFORNIA W R E NLY — 0 NOT FILL I <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page <br /> ! of r-i Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> f <br /> Owner's Well No N0 464959 <br /> Date Work Began C tr ' Ended {' r��' LATITUDE LONGITUDE <br /> ❑ <br /> Local Permit Agenc f l' 1 A ,I I t I,i I f ` <br /> Permit No € { ' Permit Date //-U( Y r rT <br /> GEOLOGIC LOG �Y WELL OWNER <br /> ORIENTATION VERTICAL - HORIZONTAL - ANGLE (SPECIFY) Name �1 �7f' r <br /> Mailing Address TOFIRST WATER (Ft) BELOW SURFACE 5 <br /> DEPTH FROM }" <br /> SURFACE DESCRIPTION <br /> Ft to Ft Describe material,grain size,color,etc CITY WELL LOCATION} I STATE ( ZIP <br /> Address <br /> ' 1 City t ! <br /> County — <br /> + APN Book Page Parcel <br /> k t l Lf or <br /> T {` -I 1 Township Range Section <br /> l" ! ar <br /> Latltlide i r NORTH Longitude WEST <br /> DEG MEN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY ��) <br /> ' NORTH _ NEW WELL <br /> 1%tilt In til`( MODIFECATIOWREPAIR <br /> r - _Deepen <br /> f 1 <br /> y Other(Specdy) <br /> f S _ <br /> DESTROY(Describe <br /> t Procedures and Materials <br /> + _,« Under GEOLOGICLOG) <br /> PLANNED USES) <br /> w_ a <br /> 3: +�'\ MONITORING <br /> �i N <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> t <br /> Irrigation <br /> I Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Descrtbe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rimers 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 (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE � FROM SURFACE TYPE <br /> DIA <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> C z MATERIAL/ CE <br /> (inches) U c� GRADE DIAMETER OR WALL 1F ANY MENT[BENI <br /> ONIFILLFILTER PACK <br /> Ft to Ft m v (Inches) THICKNESS (inches) Ft to Ft (2 ) ( (� ) {TYPElSIZE} <br /> i <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 /> Well Construction <br /> Log ` t <br /> ( Well Construction Diagram NAME � # ,�/' r 1 [+� I i {� J I { <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) <br /> — Sod!Water Chemical Analyses ' <br /> ADDRESS CITY STATE ZIP <br /> Other j <br /> Signed � i f�'e t` -� <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS WELL DRILLER AUTHORIZED REPRESENTATIVE t DATE SIGNED C57 LICENSE NUMBER <br /> i <br /> DWR 188REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />