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rQUADRUPLICATE STATE, OF CALIFORNIA D W R ONLY — T FIL IN <br /> FC.-.Cocal Requirements WELL COMPLETION REPOR' <br /> _Page._Of� Refer to lnsrruetion Pamphlet � STATE WELL NO.iSTATION NO. <br /> r Owner's Well No. r i• // No. 550805 1-1 ❑ ❑ <br /> Date Work Began / Egded f — / X41 }/ LATITUDE LONGITUDE <br /> Local Permit Agency r• �`��� �' r'rr/ <br /> �r Permit No. Permit Date '/ - r" P ' t <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION r- �� <br /> ('�) �EPTH <br /> VERTICAL .w.__HORIZONTAL _ ANGLE ,,.,,,.(SPECIFY) Name f/�` f� - � � r f/� .. r <br /> DEPTH FROM TO FIRST WATER_ (Ft.) BELOW SURFACE Mailing Addy <br /> SURFACE DESCRIPTION �!y �l <br /> Ft. to Ft. Dermbe material,grain size,color,etc. CIN STATE ZIP <br /> WELL LOCATION <br /> Address <br /> City <br /> County i+ ! I t/v <br /> APN Book Page Parcel <br /> //` / �" =� (� L Township Range Section <br /> t ! r l/V ' Latitude I I NORTH , <br /> ' DEG. MIN. SEC. Longitude WEST <br /> - DEG. MIN. I SEC. <br /> I LOCATION SKETCH ACTIVITY (✓} <br /> ' r ! NEW WELL <br /> MODIFICATION/REPAIR <br /> L / /ILL <br /> � _Deepen <br /> I <br /> I i <br /> Other(Specify) <br /> Ae <br /> - DESTROY(Describe <br /> mv Procedwesand Materials <br /> Under"GEOLOGIC LOG') <br /> ` w i I IT; tl i1 N P ANNED USES) <br /> ii <br /> ti I r� w MONITORING <br /> IWATER SUPPLY <br /> I Domestic <br /> Public <br /> Irrigation <br /> I I <br /> Industrial <br /> h I � V I Il --• <br /> _TEST WELL'. <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrofe or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE. it COMPLETE. <br /> DRILLING <br /> METHOD FLUID <br /> WATER LEVEL & 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 (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED IVELL (Feet) "May not be representative of a well's long-terrtr yield. <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ,i FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. r z q a MATERIAL/ DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> (Inches) o� GRADE MENT TONITE FILL <br /> Ft. to Ft. m c o (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� } (TYPE/SIZE) <br /> H o 4 <br /> I <br /> I <br /> I <br /> I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log / E�!/ <br /> Well Construction Diagram NAME ` I (/ /)/ �//• ` <br /> �y <br /> �..^ Geophysical Log(s) (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) /J <br /> j k' fr /�• r // <br /> — Soil/Water Chemical Analyses <br /> ADDRESS ,/ //y �`p f/ f� /,/ CITY STATE ZIP <br /> Other — �"j/I�• I J!' /*" ! Y YY r — � F� � /; <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed �T <br /> WEL DRILLER ORiZEO REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DNR[88REV 7.90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />