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ORIGINAL STAT. OF CALIFORNIA ' <br /> File with DWR WELL COMPLETION REPORT <br /> STATE WELL NO/STATION NO <br /> Page—4( ' •I Refer to Instruction Pamphlet ❑ ❑ <br /> Owner's Well No �l l`i No 5 3 3 6 4 5 <br /> Date Work Began 10 3 I Ended 10 3 few rJ �a LATITUDE LONGITUDE <br /> Local Permit Agencv o CL v`I0 IIe_ <br /> Permit No _ -?_L1 3$ _ Permit Date t �7 P 'TRS <br /> ' <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION VERTICAL __ HORIZONTAL _ ANGLE _ (SPECIFY) Name clic nn <br /> FRODEPTH TO FIRST WATER (Ft I BELOW SURFACE Mailing Address `76 ITU <br /> DEPTH <br /> SURFACEM DESCRIPTION Los iIle—s G <br /> Ft to Ft Describe mazerlal (train sire color etc CITY STATE ZIP <br /> v1 Io KEL+ALOE IO <br /> Address <br /> City .._, <br /> Count% <a-A jo"L,14 <br /> APN Book Page Parcel <br /> Township Range Section <br /> or <br /> Latitude - i i NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH 1GTIVITY (!1 <br /> NORTH _✓NEW WELL <br /> MODIFICATtOTI l REPAIR <br /> tDeepea <br /> Oiher(Specify) <br /> _DESTROY(Deecnba <br /> ' Procedures,and Marenala <br /> ` Under GEOLOGIC LOG) <br /> PLANNED UIE(S) <br /> W 4 4 ✓0L) <br /> �+ w _ MONITORING <br /> WATER SUPPLY <br /> ��_ Domenic <br /> t <br /> /`' /� �-'.`.� Public <br /> . e fi'l l+�i� r -+' Irrigation <br /> _ <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 Rtvers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> ' DRILLING }� <br /> METHOD F l 7 FLUID <br /> WATER LEVEL a YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC Z6. (t�26�� <br /> WATER LEVEL (Ft) b DATE MEASURED <br /> ESTTMATED YIELD* (GPM) d TEST TYPE <br /> TOTAL DEPTH OF BORING 7 {Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Fl) <br /> TOTAL DEPTH OF COMPLETED WELL �� (Feet) *Mav not be representative of a well's long-terra yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA c W a MATERIAL DIAMETER OR WALL IF ANY CE BEN <br /> (inches} r =� FILTER PACK <br /> is ��, GRADE MENT TUNETE FILL <br /> Ft !o Ft c,p (IneMa) THICKNESS (Inches) FT to Ft (TYPEISIZE) <br /> ai (✓ ) (✓ ) OL) <br /> S Pit 25tk qo O Q <br /> L 2t �J, a zo 7 ' 6T <br /> # 3 <br /> ATTACHMENTS (.!L) CERTIFICATION STATEMENT <br /> ..._. Geabgic Log <br /> I the undersigned certify that this report Is complete and accurate to the beat of my knowledge and belief <br /> . `�,, -- - - -• <br /> — WON Construction Diagram NAME�'At2' 'Dr-k 11 I <br /> (PERSON FIRM OR CORPORATION) (TYPED ORP TED) /^� �] <br /> Geophysical Lop(s) 32 W`�L- �t(� 4 V10. C/� `I <br /> — SodlWafer Chemical Analyses 3,61 <br /> ADDRESS I CITY STATE ZlP <br /> — Other 7f4a 711 SID <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> W RILLER/Au1HORIZE ESENTAT DATE 51GNED C 57 LICENSE NUMBER I <br /> DwR 188 REV 7 9O IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />