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DUADRUPLICE STATE OF CALIFORNIA k_ D R U E O I L Y — Do t OT FILL I I <br /> Q T <br /> For Local Re(�Ilirements WELL COMPLETION REPORT^ STATE WELL NO./STATION NO. <br /> RsJer to Instruction Pamphlet ❑ ❑ <br /> +Page_of_ ,^ ) _nn E, 578173 <br /> - Owner's Well No. LAnrupe LONGITUDE <br /> Date Work Began ��' G , En e G� <br /> Local Permit Agency <br /> M �.Permit Date '_ — ` ��" <br /> Permit Nc�!'�1'r' I .WELL OWNER <br /> GEOLOGIC LOG 1�^lr,It f. I <br /> ORIENTATION (If) _ VERTICAL _HORIZONTAL _ANGLE _(SPECIFY Name I� <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address " - <br /> DEPTHFROM DESCRIPTION �11C ( I I STATE ZIP <br /> SURFACE ITV <br /> Ft. to Ft. Describe material,grain sire,calm,etc. WELL LOCATION <br /> Address '~ <br /> City <br /> Cour., ri c�Ll 'JI r) <br /> APN Book Page Parcel <br /> Township Range Section <br /> org NORTH Longitude I .WEST <br /> Latitude EG <br /> D . MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH CTIVITY (K) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> _ <br /> other(specify) <br /> I J�{ _DESTROY(Describe <br /> Procedures and Materiels <br /> Under"GEOLOGIC LOG") <br /> r Pl,0NED USES) <br /> 3 w MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> Irrigation <br /> — Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate m Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as flaad,,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING DRILLING FLUID <br /> METHOD <br /> WATER 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 /> May not be representative of a well's long-term yield. <br /> TOTAL DEPTH OF COMPLETED WELL (Peet) y <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE `' INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. w MATERIAL/ DIAMETER OR WALL IF ANV MENT TDNBE FILL FILTER PACK <br /> (Inches) 5 s �o J GRADE THICKNESS (Inches) Ft. to Fl. (TYPE/SIZE) <br /> Ft. to Ft y k (inches) (✓) (✓) (�) <br /> ATTACHMENTS (2L) CERTIFICATIONSTATEMENT <br /> I,the undersigned,cern y that this repoA Is complete and accurate to the best of my knowledge and belief. <br /> • Geologic Log TI/Y7/,- !"k'i./r // "7- J <br /> NAME/_ `� / X <br /> Well Construction Diagram (PERSON, FIRM OR CORPORAII ) (TYPED ON PRINTED) <br /> n I <br /> Geophysical Logs) 51-441 t/ l.?�, +l i l , STATE L ZI <br /> Soil/Water Chemical Analyses ADDRESS l <br /> Other �.! Iel +/ <br /> ATTACH ADDITIONAL,INFORMATION. IF IT EXISTS. Signed WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE IGNED C-5Z LICENSE NUMBER <br /> DWR 188 REV,7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />