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D W R E N Y ^ DO NOT Ft IN <br /> QUADRUPLICATE STATE OF CALIFORNIA � <br /> F-qrr'Local Requirements WELL COMPLETION REPORT STATE WELL NO.ISTATION NO. <br /> Refer to Instruction Pampblet <br /> ole [IElto No. 550742 <br /> Owner's Well No. f LATITUDE LONGITUDE <br /> r Ended <br /> Date Work Began 4 <br /> Local Permit Agency r r <br /> Permit No. r Permil Date <br /> 'G OLOCIC LOC WELL OWNER <br /> ORIENTATION ('VERTICAL _ HORIZONTAL —ANGLE _ (SPECIFY) Name _ <br /> ) f 11/_ <br /> DEPTH TO FIRST WATER—{Ft.) BELOW SURFACE Maiiing Address <br /> DEPTH FROM pESCRIPTION //11 STAT <br /> SURFACE CITY <br /> Ft. to Ft. Describe-material,grain size,color,etc. .—WELL LOCATION­ <br /> � . <br /> Address <br /> City <br /> VC ,_ I L f` /rk County <br /> A1'N Book Page Parcel <br /> or <br /> Township Range Section <br /> Lor WEST <br /> Latitude NORTH Longitude I r <br /> DEG. MIN, SEC. DEG, MIN. SEC. <br /> 4211-115— 1- <br /> 1 f LOCATION SKETCH ACTIVITY (!) <br /> NORTH NEW WELL <br /> MODWICATIONIREPAIR <br /> Deepen <br /> i <br /> , —Other(Specify) <br /> `hSTROY(Describe <br /> )t7 Procedures and Materiels <br /> 1. Under"GEOLOGIC LOG") <br /> - PLANNED USE(S) <br /> LU a (2L) <br /> W MONITORING <br /> —ZT <br /> WATER SUPPLY <br /> E.`,,, f � Domestic <br /> i l Public <br /> \ 1 S Irrigation <br /> Industrial <br /> "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Ricers,etc. <br /> PLEASE BE ACCURATE 'v COMPLETE. <br /> DRILLING <br /> METHODLUID <br /> R LEV YIELD F COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feel) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAi. DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield. <br /> DEPTH CASINC(S) DEPTH <br /> ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE FROM SURFACE <br /> HOLE TYPE <br /> DIA. z d MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN <br /> Ft. to Ft. <br /> (inches) h �? J GRADE DIAMETER WALL IF ANY MENT TONITE FILL FILTER PACK <br /> o (Inches) THICKNESS (Inches) Ft. To Ft. / (TYPEISIZE) <br /> ATTACHMENTS (i:�) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — Wall Construction Diagram NAME �� <br /> (?RSDN, IRM, CDRPDRAZT ION) T Y P69 D DR PRINTED) <br /> Geophysical Log(s) <br /> Soil!Water Chemical Analyses >� <br /> Other <br /> ADDRESS r CRY STATE ZIP <br /> �11 <br /> /� l? rATTACH ADOlTlDNAL INFORMATION. IF!T EXISTS. Signed _E DRI E ES NTATIVE DA SIG ED -37 LICE $EYUMBER <br /> DWR 188 REV.7-WI IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />