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VK1121MAL b 1A 1 E Ul• LALIPURNiA <br /> File with DWR WELL COMPLETION REPORT <br /> Page I of Refer to Instruction Pamphlet STATE WELL NO iSTATION No <br /> Owner s Well No "2 No 3 3 6 3 9 Q <br /> Date Work Began I Ended t l 6 00 LATITUDE LONG1TLME <br /> Local Permit Agencvvki tG <br /> Permit No _ ��4 Z_ Permit Date (t 3 ' <br /> OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (.!L) VERTICAL —HORIZONTAL — ANGLE _.(SPECIFY) Name Una��� •nr< <br /> j 74 OV <br /> DEPTH FROM <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing A ress 0 <br /> SURFACE DESCRIPTION o <br /> Ft to FI Describe irratenal grain size color etc CITY STATE ZIP <br /> lS WE L LOC TION <br /> S Address <br /> 16 5t I City S 4 <br /> 3S ,,,, s,Ib- CountN _ S Stye - <br /> q45, s s APN Book Page Parcel <br /> S S6 3o..n s t kk or <br /> 6 6-7Towonship Range Section <br /> 6 7S $ Latitude_- _ NORTH Longitude WEST <br /> DEG MIN SEC MEG MIN SEC <br /> -75 SS tLOCAT NON SKETCH tTIVITY (�!) <br /> NEW WELL <br /> S !d .fir IAODtFICATIOWAI PAIR <br /> D ll <br /> Deeper; <br /> —Other(Specify) <br /> d V) DESTROY(Describe <br /> Procedures and Materials <br /> C Under GFOLOGICLOG ) <br /> I– d r PLANNED USES) <br /> LU cl K I ) <br /> W MONITORING <br /> ;j <br /> rV`t WATER SUPPLY <br /> sP- <br /> Domestic <br /> , <br /> Industrial <br /> TEST WELL <br /> i <br /> ' <br /> UTH ATFtODIC PROTEC <br /> ' SOON <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> i <br /> PLEASE BE ACCURATE G COMPLETE <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL ✓4 YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) 3 DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING 120 (Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft} <br /> TOTAL DEPTH OF COMPLETED WELL l q0 (Feet) 'Mav not be repretentattve of a wells long-term weld <br /> DEPTH BORE CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA z i MATERIAL! DIAMETER OR WALL IF ANY CE CBEN <br /> NI <br /> (Inches) J o J GRADE MENT TONITE FILL FILTER PACK <br /> Ft to Ft �, � (inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> a 1117.s a ✓ vG 3 o a l ti3.s ✓ <br /> IIS S' Ila 8 ✓ VVC 2 ,n %%3_c : 16. V1, <br /> j l(_ ; 120 ve.0 <br /> , <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 /> Well Construction Diagram NAME W ry I Ar _ <br /> (PERSON FIRM OR CORPORATION) (TYPED PRINTED) <br /> Geophysical Lops) 1 rub G q6 7 J <br /> _,T Soil/Water Chemical Analyses �O d 1 'RIO tO V t S " - <br /> ADDRESS CITY STATE ZIP <br /> — other ev - �,r rt I M/7/0Z `72.o4o <br /> ATTACH ADDITIONAL INFORMATION OF IT E)GST5 Signed <br /> ELL DRILLE lAUTHORI PRESENTAIIVE WL DATE SIGNED C57 LICENSE NUMBER <br /> DWR 188 REV 794 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />