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b <br /> ORIGINAL STATE OF CALIFORNIA q N <br /> File WI h DWR — T F I I L I N — <br /> WELL COMPLETION REPORT 0 <br /> Page O(� Refer to Instruction parnpblet STATE WELL NO+STATION NO <br /> Owner's Well No S LAI" No <br /> 562298Date Work Began <br /> Local Permit Agency C <br /> Ended LATITUDE LONGITUDE <br /> � � <br /> Permit No Permit Date A + + <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) 11� VERTICAL —HOR12ONTAL ANGLE _(SPECIFY) Name <br /> DEPTH FROM DEPTH TD FIRST AATEIJ__Z�(I't) BELOW SURFACE kNlall)ng A dress w `)Lt.r I7 I �/� ' <br /> Sl1RFgCE DESCRIPTION ~ <br /> Ft to F! Describe material,gram size color,etc CITY <br /> S r f _ WELL LOCATION STATE IIP <br /> r[,� 1 <br /> Add <br /> revr <br /> C �} <br /> &e � � � �� <br /> city (' ,7. 1;, <br /> Countv / a [p <br /> 1P or Soul. 171? Page ,(f G` .Parce) Q <br /> 1 Townsht <br /> or p Range t Sec ttnn <br /> LatitudeNORTH Longitude WES <br /> —� DEG MIN SEC <br /> LOCATION SKETCH DEG MIN SEC <br /> NORTH CTIVITY (:)- <br /> r _ NEW WELL <br /> A MODIFICATION+REPAIR <br /> rx —Deepen <br /> —Olher(Specity) <br /> +y , ! �qi �.. <br /> DESTROY(Describe <br /> Xwell Sa--11�?d✓a o Under GE'OLOGICLOG <br /> PLANNED USE(S) <br /> 3 SIN J,/ w (4) <br /> 1 131 g.i-ti wPi(K lh �+'F MONITORING <br /> Ch, � WATER SUPPLY' y `� 1� — Domest;c <br /> i I J Public <br /> v , �SLL..y♦♦1 -„� Irnpauon <br /> ' i (• <br /> Industrial <br /> ' J — TEST WELL <br /> i <br /> SOUTH — CATHODIC PROTEC <br /> TION <br /> Iffiwrate or Describe Distance of Well from Landmarks _ OTHER(Specdy) <br /> euele as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE dr COHIPLE7'E <br /> DRILLING t <br /> METHOD FLUID A 6 � <br /> WATER YEVEL & 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 <br /> TOTAL. DEPTH OF COMPLETED WELL <br /> TOTAL DRAWDOWN (Ft) <br /> (I ertj Hay not be Tep7ese?!1Xne of a;;,ell s long-term yield <br /> DEPTH CASINGS) <br /> r-ROM SURFACE BORE DEPT!I A V \I U L A R MATERIAL <br /> HALE TYPE �) FROM SURFACE <br /> DIA INTERNAL GAUGE SLOT SIZE TYPE <br /> �c W o MATERIAL/ CE BEN <br /> Ft to Ft (inches) < QU GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> m �'� (Inches) THICKNESS (Inches) Ft to Ft MENT F01{ITE FILL <br /> (TYPE/SIZE) <br /> .� t A <br /> 43 !� <br /> ATTACHMENTS (!) CERTIFICATION STATENIENT <br /> Geologic Log I the undersigned certify that this report IS complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME rl Z l 1 n & TeStincr. Inc. <br /> Geophysical Logs) (PERSON r1nm OR CDRP¢RAPON) (TYPO OR PRINTED) <br /> Soib Water Chemical Analyses S owe Q Martinez CA 94553 <br /> ' <br /> Other ADORE CITY STATE IIP I <br /> i <br /> ATTACH ADDITIONAL INFORMATION 1F 1T EXISTS Signed — 485165 <br /> j <br /> WELL DRILLER AEPRE5EN ATSN;NED _ C 57 LICENSE NUMBER <br /> DWR 1&1 REV 7 go IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />