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ORIGINAL STATE OF CALIFORNIAR Y N I N <br /> File with DWR WELL COMPLETION REPORT <br /> Page I of Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner s Well No — 2 g t 1 8 No 31 3 6 4 El <br /> Date Work Began 11 Da Ended h LATITUDE LONGITUDE <br /> Local Permit Agenc% �-t^ v 1 iC 14 <br /> • <br /> Permit No AP ! I <br /> 2.X38 N Permit Date 14 (* � <br /> GEOLOGIC LOG '' 1} WELL OWNER qq <br /> ORIENTATION (�) I/yERTICAL — HORIZONTAL _ ANGLE _ (SPECIFY) Name�/Y10e -1 ��UDr ae% _ <br /> DEPTH TO FIRST WATER (Ft) REI OW SURFACF Mailing Ad rens ?0 oX "7600 <br /> DEPTHFROM ' <br /> SURFACE DESCRIPTION ONS" <br /> Ft to Ft Describe material •grain nze color,etc CITY STATE ZIP <br /> WELL LOCAT Ol, N <br /> r t vt Address_ E, I4i yw_T - <br /> + Cit, <br /> CauntN a jon6 Q 0 tr <br /> APN Book Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> Latitude - , , NORTH Longitude , WEST <br /> ' DEG MIN •SEC DEG MIN SEC <br /> LOCATION SKETCH ye IVITY {z} <br /> NORTH _✓NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> „Other(Specify) <br /> Vr <br /> , tp <br /> Id v1 _DESTROY(Oesenbe <br /> R Procedures and Meteosis <br /> Under GEOLOGICLOG ) <br /> w C PLANNED USE(S)- <br /> LU <br /> SE(S)W MONITORING <br /> WATER SUPPLY <br /> ISP-za U Q <br /> I + Domestic <br /> , <br /> Public <br /> ' E 1"S tiler Ue Irrigation <br /> �- Industrial <br /> , <br /> TEST WELL <br /> i <br /> CATHODIC PROTEC <br /> SOUTH 2TION <br /> Illustrate or Describe Distance of Well from,Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRIL-LING <br /> METHOD ' ' / FLUID <br /> "ATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD* (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL___r.�_ (Feet} 'Mav not be reprerentame of a well s long-teem weld <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HARE ✓ FROM SURFACE TYPE <br /> TYPE _ <br /> DIA t W d MATERIAL! DIAMINTETER GAUGE SLOT SIZE CEBEN(Inches) z 1=-1 <br /> . F DIAMETER OR WALL IF ANY FILTER PACK <br /> MENT TONITE FILL <br /> Ft to F1 m N $� � GRADE {Inches} THICKNESS (Inches! Ft to Ft (TYPE/SIZE) <br /> © � rte) (�) rte► <br /> 0 72. 8 ► L SL166 <br /> 72.5 ' vc- 2 -7 -71 ✓ <br /> ; <br /> -71 ? <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> — <br /> Well Construction Diagram NAME �"^'S���"-- yr-\11`A <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRI D). ,.`Y_ Q LAS L� ']ell2- <br /> Geophysical Log(s) 363 rG7 Cl r`t<� t 6111ct U%Z l./ t 1 6 + ` <br /> SOA!Water Chemical Analyses . 6 <br /> ADDRESS /' CITY �7 STATE LIP <br /> Other a �� IF.'7l0D -7175-to <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed PI 4 <br /> WELL DRILLER/ UTHp IZ ESENTA VE DATE SIGNED C 57 LICENSE NUMBER <br /> DWR188REV 790 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />