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ORIGINAL STATE OF CALIFORNIA Y — 00 N T I <br /> File with DWR WELL COMPLETION REPORT <br /> Page i Of_J_ Refer to Instruerron Pamphlet STATE WELL NO tSTATKW NO <br /> Owner's Well No L) V~ 2` No r� D <br /> Date Work Began I ( Ended to 3 1/&V 35 3, 3 6 3 6 LATITUDE LONGITUDE <br /> Local Permit Agency �.l <br /> Permit No _2 q 3 sq Permit Date 100-7 LoyAPNITRSIOTHER <br /> � GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) V VERTICAL — HORIZONTAL _ANGLE ,— (SPECIFY) Name U v%a C&A i"L Mr1 <br /> DEPTH TO FIRST WATER—(Ft) a '1 <br /> DEPTH FROM BELOW SllRFA(F Mailing Address a3C <br /> SURFACE DESCRIPTION Lao GA 17000 <br /> Ft to F( Describe materialCITY STT <br /> TE_size color etc E ZIP <br /> 3 WELL LOCATION <br /> Address 1 7 0 <br /> C-L 5M wt t S CitV <br /> $ I e St <br /> 13 S Count <br /> r"I APN Book. Page Parcel <br /> 23 w L SM Township Flange Section <br /> 23 26.5 ' or <br /> Latitude ), NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH TIVITY (�} <br /> NORTH �[ NEW WELL <br /> MODIFICATtONIREPAIR <br /> 1 ' <br /> Other(Specify) <br /> —DESrROY(Describe <br /> Procedures and Materials <br /> Undw GEOLOGICLOG) <br /> PLANNED USE(S) <br /> uj <br /> 3 _ W MONITORING <br /> WATER SUPPLY <br /> ( VVI — Domestic <br /> _ _ Public <br /> �. Irnpehon <br /> Industrial <br /> - TEST WELL <br /> SOUTH CATHODIC PROTEC <br /> 1 TION <br /> Illustrate or Describe Distance of Well from Landmarks w_ OTHER(Speedy) <br /> such as Roads Buildings Fences Ricers etc <br /> PLEASE BE ACCURATE tr COMPLETE <br /> DRILLING �sfi <br /> METHOD FLUID <br /> WATER LEVEL & IIELD OF COMPLETED VEL <br /> DEPTH OF STATIC ip t <br /> , <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 216 S (Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 2 s (Feetl 'May not be repretematize of a well's long-term weld <br /> DEPTH BORE CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> D(Ax W —ti MATERIAL! INTERNAL GAUGE SLOT SIZE <br /> (Inches) c DIAMETER OR WALL IF ANY CE BEN <br /> Ft to Ft y �, GRADE (Inches) THICKNESS MENT TONiTE FILL FILTER PACK <br /> pnches) Ft to Ft (TYPE/SIZE) <br /> I V vc_ SCO O 11 ✓ <br /> 16, c q0 U, OZO k ✓ <br /> 13 26 <br /> ATTACHMENTS {!) CERTIFICATION STATEMENT <br /> Geologic Log I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> wan Construction Espies, NAME CC-S } <br /> Geophysical Lops} tM1nl _ <br /> (PERSON FIRM OR CORPORATION) (TYPED RINTED) <br /> — <br /> SoiitWaterChemicalAnalyses 3632 Oft Cticje CA gS7c12- <br /> Other ADDRESS CITY STATE ZIP <br /> ! 12 � lTjJl <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed M <br /> ELL DRIiLERlAUTHORIZE E ESENTATIY DATE SIGNED C S7 tiCENSE NUMBER <br /> DWR 158 REV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />