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QUADRUPLICATE STATE OF CALIFORNIA r— WR SE -ONLY — N 7 F 1 I H <br /> mor:Mbcal Re uirements WELL COMPLETION REPORT <br /> �/ Refer to Irtt[raction Pamphlet STATE WELL NO,ISTATION NO. <br /> Owner's Well No. ArtI" NO' 5 5 0 7 4 <br /> Date Work Began <br /> l� Ended /�, 7 9_�. LATITUDE LONGITUDE <br /> Local Permit Agency l tr< tl,, 1 <br /> _ �4r• N! ! <br /> Permit No. r, �� I�^ Permit Date <br /> OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (`f) _� VERTICAL — HORIZONTAL —ANGLE _(SPECIFY) Name <br /> L)EPTH TO FIRST WATER_ (Ft.) BELOW SURFACE Mailing Address it A�" U <br /> DEPTH FROM ! l 'I t t <br /> SURFACE D E S C R I P T I O N CITY TATE ZIP <br /> Ft. to Ft. Describe material, sin siu,color,etc. L W CAT, <br /> Address <br /> ti i�f /LL- Cit} ! <br /> ll16v c f County f A <br /> /✓! APN Book Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> Latitude NORTH Longitude I , WEST <br /> DEG. MIN. SEC. DEG, MIN. SEG. <br /> f LOCATION SKETCH ACTIVITY (iL) <br /> NORTH NEW WELL <br /> 10- <br /> C: t <br /> MODIFICATION!REPAIR <br /> ...�. _. r..r _Deepen <br /> (,( Other(Specify) <br /> DESTROY(Describe <br /> Procedures n <br /> Under"GEOLOGIC LOG.) <br /> N PLANNED USE(S)- <br /> Lu <br /> SES)W <br /> W MONITORING <br /> WATER SUPPLY <br /> J Domestic <br /> Public <br /> Irrigation <br /> moi/ Industrial <br /> N. "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> ' Illustrate or Describe Distance of Well from Landmarks OTHER(Speciy) <br /> such as Roads,Buildings,Fences,Rivers,eic. <br /> PLEASE BE ACCURATE, & COMPLETE. <br /> DRILLING rI&I <br /> METHOD t f FLUID <br /> WATER LEVEL & YIE D OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) S TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hra.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) •May not be represerttafive of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE : FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA. z MATERIAL! CE- BEN- <br /> (Inches) 7 o� J GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. in 3a+ (Inches) THICKNESS <br /> y o (Inches) Ft. to Ft. (TYPE/SIZE) <br /> , <br /> , <br /> ATTACHMENTS (t) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Logr .•;;��//f <br /> Well Construction Diagram NAME1/19_ C/. <br /> Geophysical Log(s) <br /> (PERSO , rl OR CORPORATION) (TYPED OR PRINTF <br /> — Soil/Water Chemical Analyses <br /> _ e w j /J <br /> ADDRESS S CITY STATE ZI <br /> Other `� / �- I/c <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> W DRILLE A HO D REPRESENTATIVE DAT SIG ED C-57 LICENSE NUMBER <br /> DWH 188 REV;-sD IF ADDITIONAL SPACE�15 NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />