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UH1421NAL STAIL OF LALiEURN1A — <br /> File with DWR WELL COMPLETION REPORT <br /> Page of L Refer to Instruction Pamphlet STATE WELL NO lSTATION NO <br /> Owner's Well No {J ~ 2 3 No 5 3 3 6 3 3 F] D <br /> Date Work Began I 0V Ended C 1 l 3 Cn t LATrtuDE LONGITUDE <br /> Local Permit Agency av- a v f <br /> . Permit No __ Zq 3 S S Permit Date ` r <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (� VERTICAL _HORIZONTAL _ ANGLE — (SPECIFY) Name w0 taPa,4-%0,A <br /> DEPTH FROM <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing ddress —76th <br /> } <br /> SURFACE DESCRIPTION I- 90Dfl <br /> Ft to Ft Describe rnatenal grain size color etc CITY <br /> W E L LOCATION STATE ZIP <br /> 25 Address e- �I <br /> Cit) 5�.�k�.. <br /> i 3 S Count% Sa,.. Jf" j <br /> 8 7- 15 S APN Book Page• Parcel I <br /> 2 333 s 2 wt Township Range Section <br /> 3*3 8 5 or I <br /> •7 or <br /> .� NTH Longitude I _ wtasr <br /> DEG MIN SEC DEG MIN SEC <br /> L LOCATION SKETCH ACTIVITY (✓) <br /> y8 [s� NORTH _✓NEw WELL <br /> 53 J 8 Si a✓t <br /> MODIFICATION IREPAIR I <br /> S85 t —Despen <br /> 6 7o,S <br /> —70 S 3 / _. Other(sn•pty) <br /> 3 f� G ir.4S S ht+rG u-73 <br /> 108 i t s —DESTROY(Describe <br /> St ( W Procedwes end Materiels <br /> Untlw GEOLOGICLOO J <br /> 116 -5( 1,L PLANNED 11SE(5)- <br /> Lu a �/ <br /> LU — MONITORING <br /> WATER SUPPLY <br /> I <br /> � — <br /> Domestic <br /> s — Public <br /> E fI"�LMCr A oe _ Irrigation <br /> J <br /> J <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC- <br /> S UTH TION <br /> Tllustrate or Describe Outance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE lr COMPLETE <br /> DRILLING <br /> i <br /> METHOD Jf 5A FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC Z_r•73 i 1,��� <br /> WATER LEVEL (Ft) A DATE MEASURED ._ <br /> ESTIMATED YIELD' (GPM) d TEST TYPE <br /> TOTAL DEPTH OF BORING 2 (Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) `May not be representative of a wells long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE — <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA r z m a MATERIAL! CE BEN <br /> r z� DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to Ft <br /> (inches) J $= J GRADE (inches) THICKNESS (Inches) Ft to Ft MENT TONI7E FILL <br /> as y o (�) (�) (�) (TYPE/SIZE) <br /> U o6 ✓ VG 2 v 1 0 102 ✓ <br /> t o 20 8 G Z 5" ,40 Dow W1 107 ✓ <br /> 10-7 : 120 3 <br /> ATTACHMENTS (f) CERTIFICATION STATEMENT <br /> Geoiag— ic Log I,the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Wan Constnicttan Diagram NaME ����� W r k k <br /> Geophysical Log(s) <br /> (PERSON FIRM OR CORPORATION) (TYPED PRINTED) /? <br /> q632- <br /> 2- o vv_i Circle fA cl 1 q z <br /> Sod/Water Chemical Analyses <br /> ADDRESS STATE IIP <br /> Other ►!`�_ 12 7 <br /> ATTACH ADDITIONAL INFORMATION IF IT ENISTS S—n-d � M -71-7610 <br /> WELL DRILLER/AUtHORITED ESEN7ATIVE DATE SIGNED C57 LICENSE NUMBER <br /> DWR INA REV 7 DG IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />