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QUADRUPLICATE STATE OF CALIFORNIA T F I I N <br /> r'Fta,L`ocal Requirements WELL COMPLETION REPOR7�"1111111101 STATE WELL NO.ISTATION NO. <br /> Hefer to lnrtruc:ion Pamphlet <br /> + _Page 4_of 4— No. C t1 Q <br /> E11:11 <br /> ❑ <br /> 0 y <br /> Owner's Well No. !t1+ �' J <br /> Ir/� LATITUDE LONGITUDE <br /> Date Fork Began <br /> Ended <br /> Local Permit Agency r ��� °='� ^"� '/r.� �f�/� <br /> APNiTRSiOTHER <br /> Permit No. Permit Date ` <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (`�) VERTICAL _ HORIZONTAL _ANGLE — (SPECIFY) Name - <br /> DEPTH TO FIRST WATER {Ft.)BELOW SURFACE Mailing Address ° <br /> DEPTH FROM <br /> SURFACE DESCRIPTION STA <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY <br /> WELL LOCATION <br /> Address <br /> City <br /> County ` <br /> APN Book Page Parcel <br /> or <br /> r 't eV I a i e, Township Range Section <br /> or <br /> r Latitude I NORTH Longitude wsT <br /> DEG. MIN, SEC. DEG. MiN. SEC. <br /> 70 LOCATION SKETCH ACTIVITYO <br /> NORTH _ NEW WELL <br /> ' MODIFICATION/REPAIR <br /> Deepen <br /> 1^- ^•" '� -"' Other(Specify) <br /> } 1 j!� r •J —DESTROY(Describe <br /> f f Procedures and MaterlMs <br /> ` Under"GEOLOGIC LOG') <br /> PLANNED USE(S) <br /> w MONITORING <br /> i � ti SSSS <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> irrigation <br /> �✓ <br /> industrial <br /> re14 "TEST WELL" <br /> f / _ CATHODIC PROTEC. <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from LandmaOTHER(Speedy) <br /> such a Roads.Buildings.Fences,Rivers,etc. <br /> PLEASE HE ACCURATE & COMPLETE. <br /> DRILLING J <br /> METHOD�Il fes. /, i / /,�!FLUID <br /> WA R LEVEL h YIELI-OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (FiTt) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETE WELL (Feet) May not be representative of a well's long-term yield, <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- VTY —HOLE FROM SURFACE TYPE <br /> DIA. MATERIAL! INTERNAL GAUGE SLOT SIZECE- BEN- <br /> {Inches) GRADE DIAMETER OR WALL IF ANYMENT TONITE FILLFILTER PACK <br /> Ft. to Ft. (Inches) THICKNESS (Inches) Ft. to Ft. (TYPElSIZE) <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> _ Geologic Lag <br /> I,the undersigned, Certify that this report is complete and accurate to the best of my knowledge and belief, <br /> Well Construction Diagram NAME .! <br /> ! <br /> Geophysical Log(a) <br /> (PER'N, FIRM, R CO OR TION) (TYPED OR PRINTED) <br /> — Soil/Water Chemical Analyses t r r /' r f <br /> ADDRESS 1 CI STATE - P <br /> — Other / '7f <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed "�- /V f r� y V <br /> WELL j2ffil DATE SIGNED C-57 LICENSE NUMSER- <br /> DWR I88RE4'7-90 IF ADDITIONAL SPACE IS,NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />