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ORIGINAL STATE OF CALIFORNIA —DWR USE ONLY — D O NOT FILL IN — <br /> File with DW1R •WELL COMPLETION REPORT <br /> Page 1 Of • ,` r Refer to Instruction Pampblet STATE WELL ./jI <br /> NO. <br /> Owner's WellZ. <br /> (� "° 4 7 7 318I <br /> \�t `- -2 Ended I "1 ' - 9 LATITUDE LONGITUDE <br /> Date Work Began ti <br /> Local Permit . cy " ^S -� 1�'� l\L rel« <br /> Permit No. 4 Permit Date APN/TR /OTH R <br /> / GEOLOGIC LOG WELL OWNER �+ <br /> ORIENTATION ('L) `e VERTICAL _HORIZONTAL <br /> cc ANGLE _ (SPECIFY) Name��^STS✓�' t�� r' � --e- <br /> t( 1 -t-kj c <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Addresses SI no S. 4vIU �3 <br /> DEPTH FROM <br /> SURFACE DESCRIPTION �y�Ol.1\S CA 6?)C; <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ZIP <br /> WELL LOCATION � <br /> p.4A Address 3S iOG `L E-I 1"V 3.5 <br /> 14 8 (:3,,3 I S1­.l_Vr1\Aof city V I,eti l-� CA ClS3�115 <br /> U County. 5�►-; �c�A�"`1� <br /> I I L1 ' APN Book Page Parcel <br /> Townships Range (or=: Section __5!+ <br /> or <br /> 1 Z :CJCLAO^ T'a Latitude NORTH Longitude WEST <br /> I C. DEG. MIN. SEC. DEG. MIN. SEC. <br /> ••�� , d• LOCATTn_1J 44uFTrT4 <br /> �W �f=y0EW WELL <br /> j241MODIFICATION/REPAIR <br /> 2r) �LA�V A�.�, t •' Deepen <br /> _Other(specify) <br /> Y-0Ir.N, q fin, <br /> g f `Q1�G►1 DESTROY(Describe <br /> ZC Z C2 !n w 1 1 \ I L Z •• Procedures end Materiels <br /> J U 'l3`Qt. 4 .+ C `` Under"GEOLOGICLOV <br /> rp\ 1 <br /> Qn c ✓ Sc1 �� L a r — PLAN ED <br /> USE(S) <br /> ii c w `(tel\a (�) <br /> J l.�W N O �`(_ 1. 3 ) ©� v La MONITORING <br /> WATER SUPPLY <br /> v �\s, <br /> L gw �? \y <br /> p Domestic <br /> ^ 5 6 3 \ Public <br /> t Gl2=4 (q) Irrigation <br /> 3 3-7•S W h Ga w ` <br /> F '. <br /> Industrial <br /> "TEST WELL" <br /> yTa t) \- I / CATHODIC PROTEC- <br /> TION`6 i YJ• �J r� di W L �. — TION <br /> Illustrate.r J.—?C—Ii zDist "-!I from Lanuma.s _ OTHER(Specify) <br /> such as Rt.w's.'zuildings.Fer- A:,.^rs,etc. <br /> PLEASE %iCCURATE & COMPLETE. <br /> /. IT'D u:+r✓ S o � W'�- d C <br /> DR LLING <br /> METHOD 46-LINIII/ �`-- ) 4a:, ` FLUID <br /> 410 STt \",14h WATER LEVEL & YIELD OF COMPLETED WELL <br /> Y10 \-L ukt- nno �Q DEPTH OF STATIC 3I, qj IZIt1 f qi, <br /> WATER LEVEL (Ft.) 8 DATE MEASURED <br /> �Y+1t CI ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING �( eet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL F (Feet) *,Way not be representative of a well's long-term yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA. z s MATERIAL/ CE- BEN- <br /> (Inches) z W z v DIAMETER OR WALL IF ANY FILTER PACK <br /> a o v GRADE MENT TONITE FILL <br /> Ft. to Ft. m » (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> 2-�- 4-9 <br /> - <br /> ATTACHMENTS (2L) 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 /> �7. ////� <br /> Well Construction fJTagtetn [V('� NAME `^ ''XX 401//fin t7 <br /> (PERSON, hW. OR CORPORATION) (TVIED OR PRINTED) <br /> Geophysical Log(s) ?vss_3 <br /> Soil/ ter Chem, al Analysesw✓ <br /> ADDRESS CI STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed WELL DRILLER/ THORIZED REPRESENT GATE SIGN C-51 LICENSE NUMBER <br /> DWR18BREV 7-so IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />