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ORIGINAL STATE OF CALIFORNIA N F I I N <br /> File with DWRWELL COMPLETION REPORT <br /> WELL NO/STATION NO <br /> Refer to <br /> Page rn <br /> O{ � Instruction Paphlct STATE ❑ El <br /> Well No U - 22- ND533632 <br /> Date Work Began E 1 7 e;ti Ended t I rZOD LATITUDE LONGITUDE <br /> Local Permit Agencv W <br /> • a.r. ry U <br /> Permit No ,.2�3 gs Permit Date 10,N,-I APN/ f <br /> +/ GEOLOGIC LOG r ' ! WELL OWNER <br /> FDEPTH <br /> NTATION (:) VERTICAL HORIZONTAL _ ANGLE (SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft I BELOW SURFACE Mailing Address 3o 6 <br /> Ot <br /> FROM <br /> SURFACE DESCRIPTION l� <br /> Ft to Ft Describe material grain size calor etc CITY STATE ZIP <br /> WELL LOCATION <br /> hY` no o Address <br /> t✓I V% S l U -23 Cltti <br /> County oLan v <br /> APN Book Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> Latitude DEG MIN SEC NORTH Longitude DEG / MIN MSEC WEST <br /> LOCATION SKETCHr1_CTIVITY (:L1_ <br /> ' NORTH _✓NEW WELL <br /> ' MODIFICATION/REPAIR <br /> i <br /> Deepen <br /> Other(SPecih') <br /> DESTROY(Describe <br /> Procedures and MaWnals <br /> Under GEOLOGICLOG) <br /> _ PLANNED USES) <br /> U) <br /> w <br /> r13 +, w MONITORING <br /> 1 t� WATER SUPPLY <br /> i 1 <br /> �.... Domestic <br /> S ,,,_, Public <br /> 4C M..�-�„G _ trnatpn <br /> _ � Industrial <br /> ' - TEST WELL <br /> _ CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Descnbe Dtstance of Well from Landmarks OTHER(Specity) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE it COMPLETE <br /> DRILLING <br /> METHOD^ �.^FLUID <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC2-7, 1► ZO / <br /> WATER LEVEL (Ft) S DATE MEASURED, <br /> E571MATED YIELD' (GPM) b TEST TYPE <br /> TOTAL DEPTH OF BORING 71 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 7< (Feet) 'Mav not be representative of a well's long-term Yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT S1ZE <br /> DIA ,� W c d MATERIAL r CE BEN <br /> (Inches) _� a DIAMETER OR WALL 1F ANY FILTER PACK <br /> a �, J GRADE MEN7 iONITE FILL <br /> Ft to Ft m cs coo (inches) THICKNESS {Inches) Ft to Ft (� ) ( � ) (� ) (TYPE/SIZE) <br /> 2 5cA,qQ tl q ✓ <br /> 7 <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> Geologic Log t the undersigned certify that this report is complete and accurate to the best Of my knowledge and belief <br /> Well Construction Diagram NAME aS -::, D rt l l "a <br /> (PERSON FIRM OR CORPORATION) (TYPED OR INTED) <br /> ..,._ Geophysical Lop(a) <br /> Soil/Waist Chemical Analyses 3b 3 (0 c-A 15-1 cIl <br /> ADDRESS <br /> Other c - {!'1 �`�(f- I <br /> G Y STATE y ZIP <br /> !L <br /> dY V <br /> ATTACH ADDI'"ONAL INFORMATION IF IT EXISTS Signed <br /> WELL DRILLER AUTHORIZED E SENTATIVE DATE SIGNED E57 LICENSE NUMBER <br /> DWR IaR REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />