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ORIGINAL STATE OF CALIFORNIA D R USE- Y — n O NOT FILL I N j <br /> File with DWR WELL COMPLETION REPORT 14 :. I l <br /> STATE WELL NO.i 1 l I <br /> STATION NO. <br /> J__-0f Refer to Instruction Pamphlet ❑ <br /> Page � � <br /> HA- <br /> Owner's Well No. <br /> No. 447.53 L1Q�{._, LATITUDELONGITUDE <br /> Date Work Began Ended t T <br /> Local Permit Agency 1�'"" Slk-3 AP r EA <br /> Permit No. 0 f Z�_� Permit to t , <br /> GEOLOGIC LOG <br /> WELL OW ER <br /> l� VERTICAL _HORIZONTAL —ANGLE _(SPECIFY) Name ` <br /> ORIENTATION (�) I <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE" � `Mailtn y� � <br /> DEPTH FROM t}:5r,, _�� _ (�! :. _ <br /> DESCRIPTION STATE ZIP <br /> SURFACE r� `- <br /> -CITY +l"� <br /> Ft, to Ft, Describe material,grain size,color,etc. `-\, ,.: f i WELL,". CAT 10N <br /> '44;12 <br /> ?5-41C r l <br /> Address <br /> a(i011n�t)/ l'C NYU 10 <br /> Book �1.F,, Page Parcel <br /> ' - or---. <br /> T��o'wnship.,� Range Section <br /> x ' L'3t1UdE' NORTH Longitude I e WEST <br /> ': <br /> q• r ,y (.�,.. DEG. MIN. SEC. DEG, MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (2L) <br /> �\ 4 F1 �', x� - e ✓ r -y, NORTH —NEW WELL <br /> .MODIFICATIONIREPAIR <br /> Deepen <br /> I _ - <br /> .M .t ...� <br /> Other(specify) <br /> —DESTROY(Describe <br /> Procedures and Malorials <br /> Under'GEOLOGICLOG <br /> PLANNED USES} <br /> V) /} Co ( L} <br /> .d, `._�;'r.s`•,.� _ n ` W MONITORING <br /> WATER SUPPLY <br /> ' I <br /> 5 , Domestic <br /> I Public <br /> i Irrigation <br /> Industrial <br /> I "TEST WELL" <br /> ' CATHODIC PROTEC- <br /> TION <br /> Illustrate or Descrthe Distance of Well from Landmarks ._.._ OTHER(Specify) <br /> such as Roads,Buildings,Fences,Risers,etc. <br /> PLEASE BE AGGpRATE dr COMPLETE. <br /> DRILLING PfQ 554/p ��ovr 1 U p 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_ 3___ (Fee-t�)� TEST LENGTH - - (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL___2__ (Feet) *May not be representative of a well's long-term yield. <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. r w _� MATERIAL/ DIAMETER OR WALL IF ANY CE- BEN- FILTER PACK <br /> (Inches) a oU GRADE MI&T BEN FILL (TYPE/SIZE) <br /> Ft. to Ft. m y v o (Inches) THICKNESS (Inches) Ft. to Ft. <br /> i—) (—) t—) <br /> tI I 5c4—40 — 0 ! t <br /> Il I! (){010 131,67 It`r <br /> - <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 /> ,_o(ogic Log � � n ye(�Q' TE�i 1• f� 1 <br /> Wali Construction Diagram NAMF Ct' f rI* A— �� rT Ne—. <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 1i L,10 {j f 5� L} f (��!?��D r� <br /> Soil/Water Chemical Analyses It's-- •2'ryQ p� y->r� (� C�.f\',(i�.t.�t.L t"T�' <br /> ADOflE55 � CITY STATE 21P <br /> Other <br /> ATTACH ADDITIONAL INFORMAI70N. IF/T EXISTS. Signed - - - -- <br /> WELL DRILLER/AIt2!=R1R1E11A1IW DATE SIGNED C-57 LICENSE NOMBER <br /> DWR188REV.7-so IF ADDITIONAL SPACE IS NEEDED, USE NEST CONSECUTIVELY NUMBERED FORM <br />