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ORIGINAL STATE OF CALIFORNIA <br /> File with DWR WELL COMPLETION REPORT <br /> Page of 1 Refer to Instruction Pamphlet STATE WELL NO!STATION NO <br /> Owner's Well No L) - ,Z0 No 513630 <br /> Date Work Began l{ 6' oD Ended 1 l 6 O� LATITUDELONGITUDE <br /> Local Permit Agency 74,� <br /> Permit No 2`-1 SS PermitDate 1011-7107 A ' <br /> r GEOLOGIC LOG r WELL OWNER <br /> ORIENTATION {4� Y VERTICAL — HORIZONTAL _ ANGLE _ (SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE M�iliiSg A dress -790-0 ���, <br /> DEPTH FROM <br /> SURFACE DESCRIPTION <br /> Ft to FI Describe material ,grain rize color etc CITY STATE ZIP <br /> WELL LOCATIO <br /> r-� rio tri �Lec, Address <br /> CIIIN <br /> County 54%— !T,-fl % <br /> APN Book Page Parcel <br /> Township Range Section <br /> cr <br /> Latitude i NORTH Longitude WEST <br /> OEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (!) <br /> NORTH _✓NEW WELL <br /> f MODWICATIONIREPAIR <br /> Deep <br /> Other <br /> ( <br /> r <br /> ^ _ ttiar(SPeciH) <br /> _..�DESTROY(Describe <br /> Procedurea and Matwisls I <br /> ` under GEOLOGICLOG 7 <br /> +- PLANNED USES) <br /> s Imo) <br /> MONITOR[NG <br /> r WATER SUPPLY <br /> � I <br /> J Domestic <br /> Public <br /> — irrigation <br /> Industrial <br /> �. <br /> TEST WELL <br /> I <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Speedy) <br /> such as Roads Buildings Fences Revers etc <br /> PLEASE BE ACCURATE & COMPLETE l <br /> DRILLING <br /> METHOD I FLUID <br /> WATER LEVEL & YIELD OF COMPLETED ELL <br /> DEPTH OF STATIC -7 !`// <br /> WATER LEVEL L _,;11 (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE t <br /> i <br /> TOTAL DEPTH OF BORING �7 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) f <br /> TOTAL DEPTH OF COMPLETED WELL 7 (Feet) `Mav not be represenrarrze of a well s long-term weld it <br /> DEPTH CASING(S) DEPTH <br /> ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA ,CU.Z _� MATERIAL/ CE8EN(Inches) a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK t <br /> Ft to Ft a (Inches) THICKNESS (inches) F! to Ft (TYPE7$!ZE) E <br /> 6) 1Pv C 2 5cl,,x-10 U ✓ <br /> L40 0. o io C <br /> G 3 7 3 S� <br /> ATTACHMENTS (2L) CERTIFICATION STATEMENT <br /> Geo{ogic Log <br /> I the undersigned certify that this report Is complete and accurate to the beat of my knowledge and belief <br /> �.. l <br /> Well Construction Diagram NAME as Cr.� I)f-( L l 10!1 <br /> (PERSON FIRM OR CORPORATION) (TYPED DRP EDI <br /> Geophysical Log(s) 6 3 Z � ( CA CIS 7,t rl # <br /> Sod)Water Chemical Analyses <br /> ADDRESS ITY STATE ZIP <br /> Other �2 � <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> WE DRILLER/AUTHORIZ RESENTATI DATE SIGNED C 57 UCENSE NUMBER <br /> DWR 188 REV 790 IF ADDJTIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />