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-'@RIGINAL STATE OF CALIFORNIA DwR USEONlv — DO N T I L 1 <br /> File with DWR WELL COMPLETION REPOR <br /> Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Page—of— _ I AI— 1--L El <br /> Owner's WON,— N°. 553786 <br /> ' CLATITUDE LONGITUDE <br /> S <br /> Date Work Began , ''n5�sxl <br /> • Local Permit A c c (j <br /> "f AP I TH <br /> Permit No. Permit Date 1 <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL _ HORIZONTAL ANGLE —(SPECIFY) Name <br /> DEPTH TO FIRST WATER—(Ft.) BELOW SURFACE Mailing Ad re S <br /> DEPTH FROM <br /> SURFACE DESCRIPTION CITY SAE ZIP <br /> Ft. F Ft. Des 'be materia/,gr nsiu,color,et.' WELL LOCATION <br /> Address <br /> City <br /> County <br /> '— APN Book Page y Parcel <br /> Township Range Section <br /> or <br /> LatitudeNORTH Longitude WEST <br /> DEO. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH pCTIVITY (�) <br /> NORTH �( NEW WELL <br /> MODIFICATION/REPAIR <br /> / _Deepen <br /> /y Other(SPedib <br /> ROY <br /> DESTUsiduar"GEOL GILL <br /> `.\/\\/) Procedures end Merenels <br /> \\YV Proced GEOLOGICLOG'9 <br /> PLgNNED USES) <br /> Ul W N/[� (V) <br /> W <br /> 3 MONITORING <br /> �r f WATER SUPPLY <br /> Domestic <br /> J _ Public <br /> • / Irrigation <br /> Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate o,Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Bu/ldtri Fences,Ricers,etc. <br /> PLEASE BE ACCURATE 6 COMPLETE. <br /> DRILLING <br /> METHOD-1kIIIIFLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) It 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 (Feet) 'May not be representative of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> BORE- TYPE FROM SURFACE TYPE <br /> FROM SURFACE HOLE <br /> DIA. w MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> w io i DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> (Inchae) GRADE (inches) THICKNESS (inches) <br /> Ft. to F[. (TYPE/SIZE) <br /> Ft. to Ft. _ (�) ) <br /> i <br /> ATTACHMENTS (2L) CERTIFICATION STATEMENT <br /> I,the un ersigned,certify that t 's report is complete and accurate to he best of my knowledge and belief. <br /> Geologic Log + <br /> _ Well Construction Diagram NAME �� UN <br /> iPERSO , FIRM. OR LuKru it ) ED us PRIN EO) <br /> Geophysical Logs) <br /> i <br /> Soil/Water Chemical Analyses <br /> DDRESS CI STATE ZIP <br /> Other �J� <br /> ' /(�� 7 �/` <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed + 'PJ <br /> E DRILLE UTN 0 RE E E ATIVE DATE NED C- LICENSE NUMBER <br /> DWR LRB REV.'/-90 IF ADDITIONAL SPACE IS NEEDED, Ukj NE CONSECUTIVELY NUMBERED FORM <br />