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TRYFL.ICATE STATL OF CALIFORNIA "r D W R USE ONLY Do N T FIL IN <br /> '4' -owner's Cop ELL COMPLETION REPORT <br /> Page of / -2 Refer to Irrsrrurtion Panrphlei STATE WELL NOJSTATION NO. <br /> P19Owner's Well No. �{ r--� <br /> r� a x, - 550745 ❑ ❑ <br /> Date Work Began Z E dctl c LATITUDE? LONGITUDE <br /> Local Permit Agency N &U� r I <br /> Permit No. Permit Dale AP ITR R <br /> GF,OLOCIC LOG )�1:N R <br /> ORIENTATION � _ VERTICAL ^ HORIZONTAL _ ANGLE (SPECIFY) r\Ia nu; <br /> DEPTH FROM <br /> DEPTII TO FIRST WATER (Ft.) BELOW SURVACh Xbiling Arld[2_Se t <br /> - �j/ <br /> SURFACE DESCRIPTION �;// <br /> FI, to Ft- Describe riraterial,grain size,Calor,etc, CITY STATE ZIP <br /> -]NF .I, I tl .AT 1 11N <br /> Atirlr(rs� 7 t <br /> f:uunty AAIr <br /> L l APN Hook E'a c Parcel <br /> or <br /> hu�allship li;ulgr Srctiun <br /> i or <br /> Latltllrl(' NORTH l,r)lI1tI1Cle—— WEST <br /> .DEG. WN_ SEC. AEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (zL) <br /> ' NORTH NEW WELL <br /> � _� _• �• MOINFECA710NlREPAIR <br /> 1� —Deepen <br /> k3l —Other(Specify) <br /> a <br /> DESTROY(Describe <br /> Procedures and Materlats <br /> Unger"GEOLOGIC LOG' <br /> r PLANNED USE(S) <br /> Lu a (!) <br /> W MONITORING <br /> � e <br /> WATER SUPPLY <br /> Domestic <br /> • <br /> Public <br /> lrriga(ion <br /> Industria! <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> ' SOUTH TION <br /> Illustrate fir Oescrihr Distance of well fram I,andntorks OTHER(Specify) <br /> r such as Rrxrds,B:tildiugs,Fences,Aioers,etc. <br /> PLEASE BE ACCURAT v COAIPLETE. <br /> ' DRILLING <br /> METHOD FLUID <br /> WATER LEVEL. & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WAFER LEVEL (Ft.) 8 DATE MEASURED <br /> ESTIMATED YIELD' (GPM) 8 TEST TYPE <br /> TOTAL. DEPTH OF BORING XZ1 {Fent) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feel) 'A1ay not be representaliuc of a well s long-teen yieid. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE •� FROM SURFACE TYPE <br /> HOLE <br /> DIA. z g MATERIALY INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) z •.'��g; ii DIAMETER OR WALL IF ANY FILTER PACK <br /> ¢ o�+ GRADE MENT TONITOL)E FILL <br /> Ft, to FI_ Onchesl THICKNESS (Inches) Pt. to Ft. (TYPEISIZE) <br /> i <br /> r <br /> OL) <br /> G <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> I, the undersigned,certify tNW�M <br /> ete and accurate to the best of my knowledge and belief. <br /> — Geologic Log �` R`/Well Construclien Diagram NAMF Ver, ih U <br /> (PER Lilly CORPORATON) (TYPED DR PRINIk <br /> — Geophysical Log(s) <br /> (�",` } // <br /> Soil1 Water Chemical Analyses f�'��1 I` l-2 � V� � <br /> ADDNE'.SS CIIY _..§J RTE ZIP <br /> Other �y <br /> ATTACH ADDt7tONAl INFORMATION, IF IT EXISTS. Signed �L ,r �}x <br /> 'W L DRILLER/AMHOREZED REPRESENTATIVE 6A 51 IED C-57 LICENSE NUMBER <br /> DWR ISS REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />