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UHi(ANAL b1A7h UN C.ALIIUHNIA <br /> File with DW R WELL COMPLETION REPORT <br /> Page of 1yRefer to Instructtan Parnphlct STATE WELL NO/STATION NO <br /> Owner's Well NO o-1-7 No 3 6 2 7 <br /> Date Work Began 1Q 3I Ua _ Ended / 16 31 LATITUDE LONGITUDE <br /> Local Permit Agency 51t, (�gtit, C_.r. �. „ „ <br /> • Permit No 2 3�, Permit Date 10 17 rO ' <br /> GEOLOGIC LOG ] t WELL OWNER <br /> ORIENTATION (z} VERTICAL _— HORIZONTAL — ANGLE _(SPECIFY) Name `� <br /> DEPTH TO FIRST WATER (Ft) RELOW SURFACE Mailing A dress 6�D <br /> DEPTH FROM <br /> SURFACE DESCRIPTION aS S Ck �t'ldS�_— <br /> Ft to Ft Describe material grarn size color etc CIT. STATE ZIP <br /> WELL LOCATION <br /> 83 o V%S 1Le_,� ( t vt Address 51F, r <br /> S Iti►C ` U — 16 CAN <br /> 193 R 8 ,, <br /> 10 C I t S APN Book Page Parcel <br /> 0 S 168 <1 °r <br /> D <br /> 12-0 C w Township Range Section <br /> rr�t Latitude NaRrH Longitude t 1 WEST <br /> DEG MIN SEC DEC MIN SEG <br /> LOCATION SKETCH �CTIVITY (2L) <br /> NORTH — NEW WELL <br /> ' MODIFICATION!REPAIR <br /> i <br /> Deepen <br /> Other(Specify) <br /> V, <br /> �DESTROY(Orsenhr <br /> Procedures sad sllterlafs <br /> T Under GEOLOGICLOG) <br /> N PLANNED USE(S) <br /> Lu L� 4 (,) <br /> w MONITORING <br /> r _ <br /> WATER SUPPLY <br /> E <br /> — Domestic <br /> I <br /> _ Public <br /> L MAxvef A%4,_ U-1.7 Irrigation <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 Ricers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> i <br /> DRILLING ��S <br /> METHOD } FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WEL <br /> DEPTH OF STATIC 1( 0 ( 1 2O <br /> WATER LEVEL 1 1 (Ft) $ DATE MEASURED <br /> ESTIMATED YIELD' (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING 120 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'Mav not be representatme of a well's long-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE .1 FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA z MATERIAL; FME <br /> E BEN <br /> (Inches) W z a DIAMETER OR WALL IF ANY FILTER PACK <br /> oc� GRADE NT TONITE FILL <br /> Ft to Ft m v c» (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> 0 110 8 +r V C, 2 r) 4 ec ✓ <br /> 10 120 $ VG Sd k qC) O. j0q I&JIS I <br /> X08 ; azo � <br /> I <br /> E <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT tt <br /> — Geologic Loa I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief i <br /> — wap Corietructton Diagram NAME_ caS 1 I i,4 <br /> Geophysical �� � <br /> (PERSON FIRM OR CORPORATION) (TYPED OR MINTED) <br /> — MI <br /> SOI!/Water Chemical Analyses J 6 7 z o►�C- �(r�'1� +�'rt,(�.o �'6Z_ S l•qz <br /> Other ADDRESS 9�2 <br /> � _ I�lCITY I STATE ZIPATTACii ADtNTFOly,A(. INFORMATION !F!T EXISTS Srgned V� [`," y217 L -� �^� I <br /> WELL DRIVER/AUTROR(Z]VJRJRESENTA vt DATE SIGNED C57 LICENSE NUMBER <br /> DWR 188 REV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />