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ORIGINAL STATE OF CALIFORNIA RWR USE ONLY — DO NOT FININ <br /> File With DWR WELL COMPLETION REPORT <br /> Page I of I Refer io Instruction Pamphlet STATE WELL NO!STATION NO <br /> Owner's Well NoNc 0 <br /> Date Work Began �It !� Ov Ended t t ( 55 3 3 638 LATITUDE LONGITUDE <br /> • Local Permit Agency a t c <br /> Permit No 2 Permit Date 1011-7100 APNITRI/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) VERTICAL -HORIZONTAL _ ANGLE _(SPECIFY) Name I ) t., Ctki COr[pi tc,4 1C- <br /> DEPTH FROM DEPTH TO FIRST WATER (Ft) BELOW SURFACF Mailing A dress d "760'V <br /> SURFACE DESCRIPTION a j <br /> Ft to Ft Deserrhe material RTM trze color etc CITY STATE ZIP <br /> WELL LOCATION <br /> ]IL <br /> r � Address <br /> t"i* <br /> Cit,, <br /> 2 S Count., Sam <br /> 2 1APN Book. Page Parcel <br /> or <br /> SS i Towanship Range Section <br /> s 60 St $ Latitude NORTH <br /> {{ Longitude west <br /> Q S 66 SL 1 DEG MIN SEC DEG MIN SEC <br /> `73 LOCATION SKETCH ;,ANEW <br /> (�} <br /> S ( � NORTH NEW WELL <br /> MODIFICATIONIREPAIR <br /> 7!� I l 11-71 <br /> Other(Specify) <br /> _DESTROY(Describe <br /> Procedures and Materiafs <br /> Under GEOLOGICLOG) <br /> U) <br /> Lu PLANNED USE(S) <br /> w (—} <br /> MONITORING <br /> r <br /> + 1 �r `, WATER SUPPLY <br /> I \.! <br /> ` SIP 1 Domestic <br /> _ Public <br /> t le4- <br /> /�G1i11� — IrnOehon <br /> industnal <br /> + <br /> TEST WELL <br /> SOUTH CATHODIC PROTEC <br /> ION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rtvers efe S <br /> PLEASE BE ACCURATE & COMPLETE <br /> 1 +c <br /> DRILLING t4JA <br /> METHOD FLUID <br /> WATER LEVEL 6 YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> 1 Q ESTIMATED YIELD* (GPM) h TEST TYPE <br /> TOTAL DEPTH OF BORING I l * (Fe�e�tp} TEST LENGTH (Firs) TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) `May not be repretentatt✓e of a well long-term weld <br /> DEPTH CASINGS) ANNULAR MATERIAL <br /> FROM SURFACE BORE DEPTHHOLE TYPE ! FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE CE <br /> (inches) W z� I MATERIAL/ DIAMETER OR WALL IF ANY MEN7 iONlTti FILL <br /> Ft 10 Ft oc GRADE FILTER PACK <br /> m y vo = (Inches) THICKNESS (Inches) Ft to Ft (TYPEISIZE) <br /> 0 ; l16.5 VVC 341 0 ; 6 <br /> !C ' 1 tq Pvcai 61 <br /> I.5 8 V`C 31q 1 5,J. Lro 65 0 140 b <br /> '7I_� ; - 8 ✓ VC. 2 of 7a <br /> 1r 11 �t o <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Lim I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> ( <br /> Wen Construction Diagram NAME ""0.s C f_ t <br /> Geophysical Log(a) <br /> (PERSON FIRM OR CORPORATION) (TYPED OR NTED) <br /> /+ �1 <br /> Suds Water Chemical Analyses '3(, 31?- moi~ C r 1A'Lr C A 412— <br /> ADDRESSCITY STATE ZIP <br /> ..� <br /> Other }� �ti.� <br /> ATTACH ADOtTIONAL INFORMATION W IT EXISTS Signed � r ^ � ] Vv -7( <br /> '_7�'ld <br /> WELL DRILLER/AU ORIZ9ED RE 7ATIYE DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />