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ORIGINAL STATE OF CALIFORNIAW'R — D NOT ILL IN <br /> I <br /> File with DWR WELL COMPLETION REPORT <br /> Page Of 1 0 Refer to Instruction Pamphlet 14 <br /> STATE WELL N0./STATION NO. <br /> Owner's Well No. ssAAw —z No. 447435 El El <br /> Date Work Began b/� , Ended 4 LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No. Permit Date APN/TR / ER <br /> GEOLOGIC LOG WELL OWNER �♦ <br /> ORIENTATION (!) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name SMG [ 11/epDl��}'T/E'71v <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address I-q-35- /2442i?,ET Sj ;iP_E 7— <br /> DEPTH <br /> FACEDESCRIPTION ���1J9'�ELP15�/A- 'x:114 /9ib3 <br /> Ft. to Ft. Describe Tnatertal,grain siw,color,etc. CITY ' STATE ZIP <br /> WELL LOCATION <br /> Address X43 24 6 C-f'4r#jjA'Y Q9 <br /> City 'TDIU Ah <br /> .County OtKY1.�IlAI <br /> APN Book Page Parcel <br /> 1 g r Township. Range Section <br /> or <br /> 131Latitude I NORTH <br /> Longitude wesr <br /> Pip <br /> Q DEG. MIN. SEC. DEG. MIN. SEC. <br /> L LL MM LOCATION SKETCH ACTIVITY (2L) <br /> f^ aC U L'f 1 NORTH _ NEW WELL <br /> `/ / MODIFICATION/REPAIR <br /> G G71-�tT -�N� —Deepen <br /> S _Other(Specify) <br /> r C L��°T10A1 �� <br /> CJttfZo/I _DESTROY' <br /> (Describe <br /> /s <br /> Undia"GEOLOGICLOG'y <br /> PLANNED USE(S) <br /> to a l!) <br /> W MONITORING <br /> WATER SUPPLY <br /> — Domestic <br /> Public <br /> — Irrigation <br /> Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC. <br /> SOUTH TION <br /> Illustrate ar Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE& COMPLETE. <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL If 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 (Hra.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) a May not be'representative of a well's long-term yield. <br /> D CASING(S) EPTH ANNULAR MATERIAL <br /> FROM SUR BORE TYPE ' FRO RFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> W s MATERIAL/ CE- BEN- <br /> (Incnes z '' oz� s GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> MENT TDIN FILL <br /> Ft. to Ft. _ (Inches) THICKNESS (Inches) Ft. to Ft. � ) ONI (� ) (TYPE/SIZE) <br /> ATTACHMENTS (2L) 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 /> _ <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Lags) <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE GATE SIGNED G51 LICENSE NUMBER <br /> DWR IRR REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />