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6RIGINAL <br /> 'F111e with DWRSTATE OF CALIFORNIA N Y <br /> V'f<'ELL COMPLETION REPORT <br /> Page,of Refer to Instruction Parnpblet STA WELL NO!STATION No <br /> Owners Well No No 56295 11C <br /> Date Work Began .s' Ended LATm)DE <br /> ocal Permit Agency .�EI S LONoIruoE <br /> / p <br /> Permit No Permit Date <br /> GEOLOGIC LOG W LL OWNER <br /> ORIENTATION (2!L) VERTICAL HORIZONTAL _ANGLE (SPECIFY) Name '& <br /> 1-40 <br /> DEPTH FROM DCI"I'll TO FIRST MATER IFS j BELOW Si,RFAU Mailings +% <br /> Addres7 ,f <br /> SURFACE DESCRIPTION SC - <br /> Ft to Ft Dererrae material,grain size,color etc CITY M1 3 ATEQ <br /> W r l L 1 0 T 10 ' ZIP <br /> ' Address <br /> FE wtx, C- <br /> � <br /> City 3� <br /> County IPP D Ltir 0 <br /> AP,1 Book 172Page C� Parcel rfa <br /> or <br /> 4 To anshlp Range Section <br /> Latitude_— I NORTH Longitude WES <br /> PEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY� (!)- <br /> NORTH/ _ <br /> y <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> 1 <br /> + p t S?e-}m b —Deepen <br /> + 1 <br /> Other(Speedy) <br /> 0, <br /> ' ..� 4 ` DESTROY(Describe, <br /> PrCcadures and Matenel <br /> ,,I + Under GEOLOGICLOG <br /> PLANNED USE(S) <br /> ca <br /> 3� <br /> 1x MONITORING <br /> w`Ely ] <br /> WATEq SUPPLY <br /> Domestic <br /> d / <br /> Ilk � Puoue <br /> ' A ____ Irngatlon <br /> t' 1 Q F-r�o 7� �J� I — Industrial <br /> ( �rf Z Jit TEST WELL <br /> f5l <br /> SOUTH — CATHODIC PROTEC <br /> TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such a.,Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING <br /> METHOD t4k&'LldhC <br /> FLUID_ <br /> WATER LEVET, h YIELD OF COMPLETED WELL <br /> OF STATIC <br /> j <br /> WATER LEVEL <br /> WATE � <br /> � (F() g, DATE MEASURED�.LL <br /> ESTIMATED YIELD' (GPM) $ TEST TYPE ! T <br /> TOTAL DEPTH OF BORING (F�{) <br /> TEST LENGTF! (His) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL. �_ 'Feet} "Afay 1101 be repreJentutme of u 7_ell i hang-term yield <br /> DEPTH BORE CASING{S} ANNULAR MATEAI%L <br /> FROM SURFACE TYPE DEPTH <br /> HOLE <br /> DIA z t MATERIAL! INT)RNAL GAUGE SLOT SIZE FROM SURFACE <br /> (Inches) , w x DIAMETER OR WALL IF ANY C£ BEN TYPE <br /> Ft to Ft m o` GRADE <br /> THICKNESS FILTER PACK <br /> n = (Inches) (inches) Ft to Ft ME TONITE FILL <br /> s 1 { } (2�I ( ) (TYPEISIZE) <br /> 0 L7 <br /> 0.0 ,// <br /> i — <br /> ATTACIIMENT5 (�) CERTIFICATION STATEMENT <br /> Geologic Log f the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Well Caitstruction Diagram NAME <br /> (PERSON R OR CORPORATION) (T D 0(t PRINTER) ! <br /> Geophystical Log(n) , <br /> T SGII,WalarChemical Analyses 950 Haute Road Martinez CA 94553 ' <br /> Other LAIDIDRESS ISJ�^S�TAAII DP ' <br /> ATTACH ADDIT70NAL INFORMATION 1F IT EXSTS ed riZnTF(O � r`-� 4 8 5 1 6-5 1 <br /> DWR 188 REV r 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM� SIG(VED' est LICENSE NUMBER 1 <br />