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ORIGINAL STATE OF CALIFORNIA w R USE ONLY — DO NOT FILL <br /> File with DWR WELL COMPLETION REPORT <br /> Page I of i Refer to lastruc[sor: Pamphlet <br /> STATE WELL NO/STATION NO <br /> Owners Well No No 5 33634 LATITUDE LONGITUDE <br /> ElElDate Work Began i I 3 U� Ended I I 3 ` <br /> Local Permit Agency tG 4A-fl <br /> Permit No Z 63 Permit Date (( D7� P ' <br /> TRSI <br /> GEOLOGIC LOG t (W�-E+�L�L�yO�WNIjE.�R <br /> ORIENTATION (`� VERTICAL _ HORIZONTAL _ANGLE — (SPECIFY) Name v✓"(1 GQ1 C:O ^ M' •ao <br /> DEPTH FROM <br /> DEPTH TO FIRST WATER IN) BELOW SURFACF Mailing Address 4 -76 Oa <br /> ! / <br /> SURFACE DESCRIPTION 4-O5 rA .7`1 <br /> Ft to Ft Describe material ,g7am.size color etc CITY STATE ZIP <br /> WE L LOCA T ON <br /> ' 22 r`11t^ Address L <br /> kye L 0- ZSR- Cit, <br /> Counh w <br /> APN Boot. Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> LatitudeDEG MIN SEC DEG MIN SEC NORTH Longitude I _i WEST <br /> � <br /> LOCATION SKETCH ACTIVITY (! <br /> ' NORTH NEW WELL <br /> ' 1.1ODIFICATION/REPAM <br /> i <br /> Deepen <br /> Other(specify) <br /> j' L f rdsAwe, <br /> DES_ <br /> N <br /> Procedures end Matanais <br /> 24Under GEOLOGICLOG J <br /> y PLANNED USE(S) <br /> m a� LUMONITORING <br /> r WATER SUPPLY <br /> � I <br /> _ <br /> Domestic <br /> Pawic <br /> i M(kW _ Irrigation <br /> lntlaatnal <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks _ OTHER(Specify) <br /> such as Roads Busldsngs Fences Rswrs etc <br /> PLEASE BE ACCURATE b COMPLETE <br /> DRILLING �.�[ <br /> METHOD I I JA FLUID <br /> MATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC-2,&-7 I I J2��(� <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> –�C ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING {Feet) TEST LENGTH (His) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL -7 (Feet} "Mav not be rep7wentatise of a wells long-term weld <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE SORETYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA x W c MATERIAtr DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> (Inches) a z d MENT IONITE FILL <br /> Ft to Ft m O � GRADE (Inches) THICKNESS Unchea) Ft to Ft (TYPE/SIZE) <br /> d _ <br /> V C Z 5'clL 40 O 0206'9- :' 6 3 ✓ <br /> 63 -7 <br /> ATTACHMENTS (.!!L) CERTIFICATION STATEMENT <br /> — GeologicI the undersigned certify that this report Is complete and accurate to the best of my knowledge and belle( <br /> Logy o w Dr, U%^5 <br /> Well Construction Diagram NAME .. - --- — <br /> (PERSON FIRM OR CORPORATION) (TYPO OR PRINTED) <br /> GeophysicalLog(a) Po <br /> gOyC rj 1Q ) /is 9q!5 71 <br /> Sod/Water Chemical Analyses LJ V <br /> ADDRESS CITY STATE ZIP <br /> Other fr yG r 1I ,,51 -7 209 D <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Stpne ` a' rt ! l Z. 7 l/!/ / y <br /> ELL DRILLER/AUTHO <br /> TAE DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />