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3Q . . /�47. x--z . . . .. . . .. . _... . ... <br /> ORIGINAL STATE OF CALIFORNIA ( DD W N Y go NO-i <br /> — <br /> 2th DW R WELL COMPLETION REPORT I��1 I•�qtr t , I I <br /> Rage Of G Refer to Inrtructios Pampblet ,( STATE WELL NO,ISTATION NO. <br /> Owner's Well No. �[+lo. 4 6 6 0 `-J—`—�❑��El <br /> Date Work Began ,EnIN PUB. HEALTH LATITUDE LONGITUDE <br /> Local Permit Age�gl <br /> Permit No, Permit Date APN SIOTHER <br /> GEOLOGIC LOG — ELL-OWNER <br /> JOHNORIENTATION (4) ^VERTICAL _HORIZONTAL _ANGLE( (SPECIFY) NaI(ig` %1- <br /> K i .1,ti- - 4 <br /> DEPTH TO FIRST WATER (FL)BELOW SURFACEjng•��J1`}�r <br /> t <br /> DEPTH FROM ♦ �•. 6 4 �5UA <br /> SURFACE DESCRIPTION �'_- •- <br /> Ft. to Ft. Defct11M717atCrlali in riu cola" etc,• �1\ \\ CITY t✓ i �} i � STATE ZIP <br /> WELLyJ•OCATION <br /> 41 B. ; 420 ;SAND <br /> '420 426 BROWN cr-AY <br /> e qty <br /> CPN Book 'Page Parcel <br /> 44Z ' - + \ �� TQwushi�� —Range Section <br /> ' 52,5 1 ' <br /> I <br /> �^x � + � � •`''• I:2tifude � D NORTH Longitude 1 t •WEST <br /> t 1 y i; �i• DEG, MIN. SEC, DEG. MIN. SEC, <br /> 1 ' s 't 1a ° LOCATION SKETCH ACTIVITY ('!)— <br /> D •f•'v, t ;'tai• `- -ULAY <br /> NORTH _NEW WELL <br /> b45 5b <br /> 1• ••`••• •' •••RNU <br /> • MODIPICAMONlREPAIR <br /> 1 1 '• < , _Deepen <br /> 1 i i \•..''.°5. . , ( _Other(Specify) <br /> DESTROY(Descrtbe <br /> F t• °.,; ProceduresandMeterfals <br /> Undw-GECLOGICLOG) <br /> PLANNED USE(S)- <br /> 1 1 3 to MONITORING <br /> 1 1 <br /> WATER SUPPLY <br /> 1 1 � <br /> i 1 <br /> _. Domestic <br /> e o <br /> AgaL <br /> _, Public <br /> _ initiation, <br /> ' 1 industrial <br /> t 1 <br /> .MSTWELL" <br /> CATH1 1 <br /> 1 1 SOUTH TION PROTEC- <br /> ' ' Illustrate or Describe Distance of Well from Landmarks — OTHER(Specify) <br /> such as Roads,Bufldfngs,Fences,Rimers,eta <br /> PLEASE BE ACCURATE dr COAfPLETE. <br /> D 1 <br /> D D DRILLING - <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> j 1 DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE MEASURED <br /> 1 ESTIMATED YIELD° (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be reprierentative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BOR& TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA ,c z m MATERIAL/ CE. BEN- <br /> (Mches) a3 GRADE DIAMETER OR WALL 1F ANY ME <br /> Tog FILL FILTER PACK <br /> FL to FL Unchos) THICKNESS Unchas) Ft. to FL (TYPEl81ZE) <br /> 1 1 <br /> i 1 <br /> l t <br /> / 1 <br /> 1 � <br /> 1 t <br /> 1 ! <br /> 1 r <br /> ATTACHMENTS (i�) CERTIFICATION STATEMENT <br /> _ Geotoglo Log 1,the undersigned,certify that this report Is complete and accurate to the best of my knowledge and belief. <br /> J <br /> _ <br /> Well Construction Diagram NAME /0,6� ` gNTLD (y°. <br /> _ GeophysicalLog(s) , <br /> _ <br /> Soil/Water Chemical Analyses <br /> _ P°AESSO. BOX C4•, NEN:, CT, 9 235 clTx STATE air <br /> Other <br /> ATTACH ADOM014AL IAIFORMA770M !F IF EXISTS Signed <br /> WELL DRItLFR AgTN0R1TE0 REPRESENTATIVE DATE SIGNED C•57 LICENSE NUMBER <br /> DWR188REV.7-M IF ADDITIONAL SPACE 1S NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />