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.Y TRl)tICATE STATE{ OF CALIFORNIA WR U ONLY — 00 N I FIL !N <br /> Owner's COP/iV �CGELL COMPLETION REPORT <br /> Page!a / Refer ro Inrrrrfr-irnrl Parnphler STATE WELL NO./STATION NO. <br /> Ow'ner's Well No. !f f I No. 50742 1:1 11Date Work Began /I r� Ended 0 ( 'lr I / LATITUDE LONGITUDE <br /> LOC-31 Permit Agency -Gt! LC1(U l j r �I`� <br /> Permit No. _ r J r !'rrinit I)atf APN/TR r TH q <br /> //// CE.01,OCIC LOC WELL OH'NE'R <br /> ORIENTATION (j[ � VERTICAL — HORIZONTAL ANGLE _ (SPECIFY) N�: ITEC O � '� �/ a <br /> DEPTH FROM <br /> DEPTH TO FIRST WATF11 . -.IFI! BELOW •ICF, 11ai[ing Ac [ress , <br /> r <br /> SURFACE 11 F.S C]i I I"TIO.V <br /> Ft. 10 FI. 1)ewribe nixerial,gram rr:.e,r'nlnr,eir CITY STAT dP <br /> 1'1' .E. IOC TfOV <br /> Address G' <br /> (;its' <br /> % <br /> 4 <br /> 6f <br /> ( f,rw'Ilshil) li:nlge 5eclioll <br /> or <br /> t.Ull(I]df' s I NORTH I,()I IL'It tl(II• i i WEST <br /> 6061/r _ 1 DEG. MIN. SEC DEG MIN. SEC. <br /> i LOCATION SKETCII ACTIVITY {✓I <br /> 4m, I >t>�I�� —NORTH NEW WELL <br /> 44(e 64 ilI <br /> MODIFICATION!REPAIR <br /> —Deepen <br /> —Other(Specify) <br /> O/ ESTROY(Deserioe <br /> 1 Procodwas and Msleriafs <br /> ` Under"GEOLOGIC LOG') <br /> En PLA INT M1-ED USF(S) <br /> a a { } <br /> MONITORING <br /> WATER SUPPLY <br /> �: � Domestic, <br /> Public <br /> ` Irrigation <br /> 1 f Industrial <br /> -•••"-'_—� <br /> ..TEST WELL-- <br /> _ CATHODIC PROTEC- <br /> SOUTH TION <br /> i 111—frafr ar Descnlw Dm1firwe•of L{tcll from Landmark, OTHER(Specify) <br /> s-di ds Bowl,,Buildings-Fences,Riurrs,etc. <br /> PI,F.A.SE BE ACCURATE: & COMPLETE. <br /> DRILLING <br /> ' METHOD t FLUID <br /> WATER LEN-1-1, & YIELD bF COAIPLI:TED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft_) & DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF RORIN'C �' ►�_-ll cK•f} LEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft <br /> TOTAL DEPTH OF COMPLETED WF.IA, Pe'rl) 'Afav not be represemative of a zxll's long-iernl vrelfi_ <br /> DEPTH CASINC(S) DEPTH A1IULAR NJATE,RIA1, <br /> FROM SURFACE $ORE- <br /> HOLTYPE •L FROM SURFACE TYPE <br /> E <br /> Df A. m MATERiAL1 INTERNAL GAUGE SLOT SIZE CE-TT(0�p <br /> N- <br /> {inches) z e� a DIAMETER OR WALL IF ANY FILTER PACK <br /> a oc., GRADE MENITE FILL <br /> Ft_ to Ft (Inches) THICKNESS {Inches) FI. to Ft. <br /> H o w (� ) {�) (TYPE,SIZE) <br /> ATTACIINIE-NTS (.Ll CERTIFICATION STATEMENT <br /> 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief- <br /> Geologic Log IJ �/ <br /> Wel;Construction Diagram NAME ` t C///it e- <br /> (PlRgf}N, FIRM, OR CORPORATION) (TYPO OR PRINTED) <br /> Geophysical Log(s) L / / <br /> — Soil!Water Chemical Analyses ! il/'/'^' V r_A ll- <br /> r r[1f 1 7/ <br /> ADDRE55 / CITY STALL ZIP (' <br /> Other <br /> AY7ACH ADDITIONAL INFORMATION. 1F IT EXISTS. 9rgn,p to_ DRIL /AUTHORIZED REIPRESENTATIVE DA E SIG rO 87 IICENSF. NUMBER <br /> D%%It IHx 6 PV 7.141 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />