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QUADRUPLICATE STALE U C L =�.II\tA DW= l s - 0 V L a — co Nc- _ ,,L IN -- <br />' For Local Requirements WELL COMPLETION REPORT I I 1 , I „ � 1 I <br /> Page_L_— Of I - Refer to !r t ru- an Pamphlet STATE WELL NQ ISTATION NO <br /> —111 Owner's Well No — lIg--3 _ _ No 5 0 6 3 6 ! 11 I C <br /> Date Work tae, n — /7.' CA Ended 9/9"i/9A LATITUDE LONGITUDE <br />' Local Permit Agencv e I I I I I I I I I I t I <br /> Pel mit No SRO 1 7c3 — Permit Date APNITRSICTF-FD <br /> GEOLOGIC LOG WELL OWNER <br />' ORIENTATION VERTICAL _ HOR3ZONTAL _,,.,_ ANGLE _ (SPECIFY) Name Wilbur E111r�_ <br /> DEPTH TO --tRST WATER (Ft) BELOW SLRFaCE Mailing Address 191 W. 5M-W, *107 <br /> DEPTH FROM <br /> suSPACE DESCRIPTION )”i esm CA 93704-287E <br /> Ft to Ft CITE STATE ZIP <br />' I Descr�oe rrzarenal ,grain stye coeur et., WELL LOCATION <br /> Address 212 <br /> industrial s <br /> my city St=ttorl. CA <br /> 1 Z <br /> ' COLIIItY Saa +7Da <br />' T + CPN Book Page Parcel <br /> � or <br /> T()wnshlp IN Range Fir. SeLtion � <br /> r <br /> o <br /> Latitude 3754 r 23 NOF-11-1 Longitude 121 - lb 19 wEsT <br /> DEG ' MIN SES. DCG MIN 5EC <br /> LOCATION 5KE rCH �CTI ti ITY (Z.) — <br /> ' NORTH X_ NEW WEL_ <br /> i <br /> MODIFICATIONIREPAIR <br /> — Deepen <br /> i <br /> —Other(SPttmly) <br /> CESTROY(C)ascribe <br /> Frccejures and Me lerial <br /> Under GEOLOGlGLOG <br /> PLINKED USE(S) <br /> .11 MONITORING <br /> i ! WA7E9 SUPoLY <br /> e i <br /> Domestic <br /> t <br /> Puolic <br /> I <br /> IrriQahon <br /> r <br /> Industrial <br /> i r I ti <br /> TEST WELL <br /> CATHODIC PROTEG <br /> SOUTri TIC <br /> lllarlrair or Describe D% inner Of Wt It jrorrt Lanflnlat,lr OTHER(Spec ly) <br /> fsuch m '{unds BuddinGs Fentz, RuLrS Lt- <br /> PLEASE <br /> t„PIEASE BE ACCE,,R ITE,' �- COMPLETE <br /> r , i <br /> I <br /> GRILLING <br /> I ME—Hao Hal-1=v Std ALt:,z?r FLUID INZA <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> r r DEPTH OF STATIC <br /> WATER LEVEL � �Y (Ft) & DATE MEASURED <br /> I ESTIMATED YIELD* (GPM) & TEST T IPE <br /> TOTAL DEPTH OF BORING �� (Feet! TEST LENGTH (Hrs) TOTAL DRAWDOWN (Fr) <br /> TOTAL DEPTH OF COMPLETED 1AELL (Feet) *Alav not be rcpresenronve of a well's lonig-rerm-weld <br /> DEPTH BORE CASING(5) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE () FROM SURFACE <br /> INTERNAL I GAUGE SLOT SIZE TYPE <br /> (Inches) 721N.5 <br /> z� MATERIAL/ DIAMETER OR WALL IF ANY CE BEN o�. GRADE FILTER PACK <br /> Ft to Ft �G LL (Inches) THICKNESS (Inches) Ft to Ft MELT TONITE " ) (TYPEISIZE) <br /> fes) (�) [ '') <br /> 0 30 9 X1 tvicy1 x I <br /> ,30 91XI I PVC/Sch +407 2 1 . I I <br /> I I F I28 50 II x 1 :3 Sand <br /> III I I <br />� I ATTA.CHMENTS (tL) CERTIFICATION ST{TEMENT <br /> I <br /> ._._ Geologic Log I, the undersigned Cer-Iry that this report is complete and accurate to the best of my knowledge and belief <br /> I Y <br /> T Well Construction Diagram NAME r� } <br /> — Gegonysical Log(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Soil/Water Chemical Analyses <br /> Other ADDRESS CITY STATE 21P <br /> ATTACH ACDITICNA♦_ INFORMATION IF IT $"lSTs Sr9nad <br /> WELL DRILLER/AUTHCF-ED REPRESENTATIVE GATE SIGNED __11:1:111CrdSE NUM6ER <br /> 1)Wit IrshHLV -110 IF ADDITIONAL SPACE IS NEEDED Ute= NE<T CONSECUTIVELY NUMBERED FORM <br />