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ORIGINAL STATE OF CALIFORNIA w R N LY — DT F 1 + <br /> File with DWR WELL COMPLETION REPORT <br /> l <br /> Page of Refer to Instruction Pamphler STATE WELL NO/STATION NO <br /> Owner's Well No S P' 3 i� No lgo5 3 3 6 4 2 <br /> Date Work Regan I I a T Ended t t LATITUDE LONGITUDE <br /> • Local Permit Agency <br /> Permit No ZqZPermit Date It 3' " <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (t ) VERTICAL — HORIZONTAL — ANGLE _(SPECIFY) Name r f� <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACF Mailing Address e70 -76 CIU <br /> DEPTH <br /> DESCRIPTION tiOs A,.nar_ S CA ct!m!!� t <br /> Ft to Ft Deserrhe matertal grain size color etc CITY WELL LOC TION STATE ZIP <br /> o n Address G- <br /> S 22 Cit. <br /> Count\ 19 10 1h <br /> APN Book Page Parcel <br /> Towor <br /> nship Range Section <br /> i or <br /> Latitude I NORTH Longitude � wEsr <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (iL) <br /> NORTH ✓_ NEW WELL <br /> p} MODIFICATION/REPAIR <br /> Depen <br /> other(SAecdy) <br /> Y f0eacrihO <br /> r-DESTRProcedup es and Ma ertets+ <br /> ' Q Under GEOLOGICLOG ) <br /> Q.6 PLANNED USE(S)– <br /> W � { ? <br /> MONITORING <br /> r WATER SUPPLY <br /> 154-38 <br /> Domestic <br /> Public <br /> • <br /> 1') ) <br /> t w A.,,r- 1Jl- — Irrigation E <br /> industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> r SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE dr COMPLETE <br /> DRILLING FT!'A <br /> METHOD 7 FLUID <br /> WATER LEVEL & 11ELD 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 (Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL - (Feet) "May not he representative of a well's Jonz-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLAT SIZE <br /> DIA ie W o d ]MATERIAL/ DIAMETER OR WALL IF ANY E BEN FILTER PACK <br /> (Inches) �� s GRADE MENT TONITE FILL <br /> Ft to Ft v (inches) THICKNESS (inches) Ft to Ft (TYPE/SIZE) <br /> in H — (!) (—' ) f—' ) <br /> 72, g ✓ I I IPVC go a 6� <br /> 72, g vcc 2 6 -7 <br /> -7 5 <br /> ATTACHMENTS 0:) CERTIFICATION STATEMENT <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> T <br /> Well Construdlon Diagram NAME_ <br /> GretaphYalcei log(a) (PERSON FIRM OR CORPORATION) (TYPfD OR PRINTED) <br /> O s� R,Q \/t5� c� <br /> Sod/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other rI I'Zl? db '72 oqo y <br /> ArrACH ADDITIONAL INFORMATION IF IT EXISTS WELL WELL DRILLER/AUTHORIZ D R£SENTA E O0.TE SIGNED 757—LICENSE NOM9ER <br /> VWR 188 REV 7 00 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />