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V f1I6711YHL <br /> aLAtt ur L.AL.iruni%tA <br /> File with DWR WELL COMPLETION REPORT <br /> Page 1 OE I Refer to Instruction Pamphlet STATE WELL NOISTATION NO <br /> Owner's Well No 1J TIDate Work Began I l I t�D Ended I I , <br /> 1 No 5 3 3635 LATITUDE LONGITUDE <br /> Local Permit Agencv 5xxyx C— t+l u It GHP,1 <br /> Permit No Z g 3 8 j _Permit Date b P7 In APNiTRSiO ER_ <br /> GEOLOGIC LOC r , WELL OWNER <br /> ORIENTATION {✓) VERTICAL —HORIZONTAL _ ANGLE _, (SPECIFY) Name v c <br /> DEPTH FROM DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing A dress 0 —(COT) <br /> SURFACE DESCRIPTION O'aS'I <br /> Ft to Ft Describe material gram size color etc CITY STATE ZIP <br /> ELOCATION <br /> U <br /> 0.!) Address was 5 L t (_L <br /> �'3 BC tc. NI cats 7rec <br /> Ca 51147 <br /> County aS4 v <br /> +�a 23 ► gal 5ain APN Book. Page Parcel <br /> C3 ' 20 or <br /> Township Range Section <br /> a <br /> ,, <br /> 3Latitude DEG MIN SEC DEG MIN NORTH Longitude – SEC WESr <br /> 1.3 I � � SL� <br /> 3 <br /> LOCATION SKETCH AETIVITY (�}I. S 3 8 S► Sa,� NORTH �✓NEW WELL <br /> 38 Y3 S <br /> MODIFICATN)NIREPAIR <br /> .] <br /> �4�J 3 Spa 5� ( �. C,.,a.�! I <br /> _ <br /> S O GLS t�7' Other pautY) <br /> Deep— <br /> S6 63 I �,,� <br /> 3 76 U, L►o4sa <br /> Are— <br /> DESTROY <br /> 8 ISS M <br /> G,,► Procedures and atensls v_�g Under GEOLOGICLOG) <br /> 9 3 5► C i- PLANNED USES} <br /> HSLu <br /> }8 103 I`� , _.�. MONITORING <br /> ' W t ia, WATER SUPPLY <br /> 103 � 106 �-- - <br /> 106 115 S t Dan.earc <br /> L �. C <br /> 13 120 // — Public <br /> E M t w Ave Irrigation <br /> i <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks w OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE U COMPLETE <br /> DRILLING [� <br /> METHOD ✓ FLUID <br /> WATER LEVEL 6 YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC��f e <br /> a <br /> WATER LEVEL�iT (Ft) A DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 120 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL. (Feel) "May not he representative of a-well's long-term yield <br /> DEPTH BORE CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE f✓ FROM SURFACE TYPE <br /> DIA z W o d MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) o a GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to Ft v (inches) THICKNESS OncheO Ft to Ft MENT TONITE FILL <br /> (r ) (� ) (� ) (TYPE/SIZE) <br /> Ito 8 V1 I I Pvc 2 <br /> 5<_ q0 D t o ►l <br /> ro 120 8 ✓ G V2 o o_oZa to ld 8 <br /> 108 (2o 3 <br /> ATTACHMENTS (t) CERTIFICATION STATEMENT <br /> — Geologic Loc I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> — Well Construction Diagram NAME I <br /> — Geophysics)Log(a) <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> � <br /> Soil Water Chemical Analyses 36 2 Q M"�G Ct(a � <br /> te. a vo, C-A C75-742 <br /> ADDRESS CITY STATE ZIP <br /> — Other —7 r-7 <br /> ATTACH AD➢fT)ONAL INFORMATION IF jr EXfSTS Srpged n 2 L !! <br /> ELL DRILLERlAOTtfORI PRESENTA YE DATE 51(iNED C57 LICENSE NUMBER <br /> DWR188REV 780 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />