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Vllltl!l�ML �anac �a �.na.aa�a„�an - - - <br /> File with DWR WELL COMPLETION REPORT <br /> Page I of I Refer to Instruction Pampblet STATE WELL NO/STATION No <br /> ❑ ❑ <br /> Owners Well No U—2 1 No <br /> 533631 <br /> Date Work Began 1 1 3 CTS Ended I t LATIruDE LONGITUDE <br /> Local Permit Agenev LLC- 1 <br /> 21385 ro r vU APNITRSIOTHLO <br /> Permit No Perm Date <br /> ✓/ GEOLOGIC LOC WELL <br /> �OWNER <br /> ORIENTATION (.!L) VERTICAL HORIZONTAL _ ANGLE (SPECIFY) Name -_ h4C-Ij <br /> DEPTH FROM <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address ?Q 0 7`02 SURFACE DESCRIPTION 'L qqV$"1 <br /> Ft to Ft Describe material (warn size color etc CITY STATE ZIP <br /> 16 ' C t,I sa^e� Address .51A,_ ELL LOCATI <br /> i r <br /> S 13 ( t City �. <br /> 13 I S Lvl I County ~, <br /> I8 23la,ew S APN Book Page Parcel <br /> 23 ' '3 SI or <br /> 3 6 3$ To unship Range Section <br /> L Of <br /> . NORTH Longitude + WEST <br /> 8 1 r,.Jt St DEG MIN SEC DEG MIN SEC <br /> q I LOCAT)oRKETCH ".CT]VITT (�) <br /> NEW WELL <br /> t13 418 C e I <br /> MODIFICATION/REPAIR <br /> + <br /> —Deepen <br /> S 8 <br /> .,an«(Specify) <br /> 4- <br /> r + 14-1 V —DESTROY(Describe <br /> 3 / g t cl d Pracedurea.nd Meten.fs <br /> CJ L .+ 7 Under GEOLOWCLOG) <br /> 68 70.6 S PLANNED USES) <br /> 70•�' • 3 ' t }' w t C 3 W MONITORING <br /> 75 `73 8 WATER SUPPLY <br /> 7S,8 -7 8 C i r — Domestic <br /> 7 <br /> PublicS �� _ Img,tgn <br /> o�Il <br /> C _ Industrial <br /> gs 139 TEST WELL <br /> ge 113 C, :51 <br /> cATigolc PRorec <br /> i i3 120 ; I So(,TH TION <br /> Illustrate or Describe Dtstance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE Cr COMPI,E'T,E <br /> DRILLING <br /> METHOD //!"'"' FLUID <br /> WATER LEVEL & YIELD OF COMPLETED ELL <br /> DEPTH OF STATIC. 7_�2 t t Zt7 �D <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) 5 TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL IZ© (Feel) 'Mav not be reprerentatme of a well';long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL I <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> — INTERNAL GAUGE SLOT SIZE <br /> DIA �z ec a MATERIALI DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> (Inches) z J GRADE MENT T4NITE FILL <br /> Ft to Ft N _ (inches) THICKNESS (Inches) Ft to Ft (�L (� ) OL (TYPE/SIZE) <br /> 119 120 S V1 I P UC_ 2 0. OZO 10 (08 <br /> lob Iso I-#3 S.,J <br /> ATTACHMENTS CERTIFICATION STATEMENT EE <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belle( <br /> Gaologic Log <br /> Wap ConstructiO4%0924fam NAME <br /> Geophysical Log(s) <br /> (PERSON FIRM OR CORPORATION) (TYPED Off PRINTED) <br /> '3657- ^ r O co <br /> Sail/Walar Chemical Anetypes I^"�G �l('1+,� irl^L„ .(t^L` ' <br /> ADDRESS ,,�^ `�r ITV r STATE ZIP <br /> Other ATTACH ADDRIOA)AL tNFORMATFON 1F IT EXISTS Signed L " ""^ 2 ,in r I <br /> WELL DRILLFR/AUTHORQE P ESENTATI PATE SIGNED C57 LICENSE NUMBER <br /> DWR198REV790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />