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3q <br /> OWGiNAU. STATE OF CALIFORNIA Ia E O Y01A <br /> ".. <br /> F114-with D,,}}WR WELL COMPLETION REPORT Page" Ot' Refer to dsrrructfon PamAblet STATE WE <br /> Owner's Well No. _ -� No. 475421 �� n <br /> Date Work Began 5/30)0t(v , Ended 3 LATIZUDE. LONGITUDE <br /> debPie_rfTlit Agency .I ti—ra4� rT <br /> Permit No. a� '01��`7 .Permit D +04)A IP —APNITRS/OTHER <br /> } GEOLOGIC JOG ` ,, WELL OWNER <br /> ORIENTATION '' rr <br /> (�) VERTICAL —wRiZONrAL _ANGLE e(SPECIE» Na1tTe r+. L •�)jyQ �G� e <br /> DEP_Tti•FttotA•" DEPTH TO FIRST WATER'—MA(FL)BELOW SURFACE ' 'Mai n, AXd>e{s - <br /> U,'!' IC; �v SURFACE DESCRIPTION <br /> I. to Ft. Describe materia! ain size color etre i � c'TY . STATE ZIP <br /> =.iLOCATION <br /> tL r+r ( t•AC�drC55 � fit+ ,e � 4 C Ui1) <br /> 42r 12 -5 :15IL 5AW m)r- JA,3A brn' 5Aj 1; <br /> t1Pill Book Page Parcel. <br /> TowwnshiP Range Section <br /> S •,.'CL ' t -�YYo- +t: 1 (tiftiile 1 1 NORTH Longitude , WEST <br /> ' iIt SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY <br /> '�� )•r. NORTH <br /> NEW WELL <br /> {y ( W�tr� t _ MODIF(CAnONfREPAIA <br /> + + . I�B� _Deepen <br /> .Or 1N 11 r r� <br /> Othw(Specify) <br /> 1 :,• , DESTROY(Describe <br /> A,'vs.'tG L ✓.e. r PFccedaresandmateneis <br /> 81P.0 &61-Q II.• r r r (�r UadeF"GEOLOGlCLOG-) <br /> e, N PLANNED USE(S)- <br /> 1 <br /> V+r <br /> ico 1 to " <br /> V f`'[�11 to \—I MO BORING <br /> 1 ��CE\VE L1.� rrL 132 } t WATER SUPPLY <br /> Jai r — Domealic <br /> 4=001 <br /> Q' ' \ t r — Public <br /> e . G — "gallon <br /> - <br /> �,. r r .^c 4 � Mduslrtel <br /> 0!1009 T! SA N \ l, �Ms- ' r F. prve-tr6 60 W,-,,0. "TEST WELL•• <br /> i� _ t. <br /> r`r1 —CATHODIC PROTEC- <br /> (.Qi 5'. 11.7,a Stt�-r ML + k ' f 1 jb.r�d SOUTH <br /> �• Ilfustrate or Describe Distance of Well from Landmarks _OTHER(Specify) <br /> 112 Q'l 3 3 r 7' S t(, ' ND Srr,�r r <br /> such <br /> a , C � MPE <br /> N BEtAG(IATE�COPE <br /> r r DRILLINfl t rt+e1�R{� <br /> ti ®; (" cY6 Tn METHOD a r� FLUID MA <br /> • ' ' WATER LEV & YIELI) OF WELL <br /> r DEPTH OF STATIC <br /> WATER LEVEL p4•Q, (Ft.)& DATE MEASURED <br /> ' ESTIMATED YIELD' -. (GPM) &TEST TYPE <br /> r l TOTAL DEPTH OFBORING 1- Q.,4 (Feat) TEST LENGTH ^ (Hrs.)TOTAL DRAWDOWN <br /> TOTAL DEPTH OF COMPLETED WELL 114,5—(Feet) •May not be representative of a•well's long-term yield <br /> DEPTH CASINC(S) ! ANNULAR MATERIAL <br /> FROM SURFACE HOSE �rPE ✓ FROM SUR ACE Ct M1 TYPE <br /> DIAL W MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> (Inches) zt' m DIAMETER OR WALL IF ANY CE- BEN- <br /> Ft. to Ft. GRADS MENT 70NftE Fitt FILTER PACK <br /> c'y3 (inches) THICKNESS (Inches) Ft. to FL TYPE/SIZE) <br /> (`') ('') (`') <br /> 1 � <br /> ' 1 <br /> ' 11,104 <br /> ✓ ' <br /> ATTACHMENTS <br /> (—) CERTYFICATION STATEMENT <br /> _ Geologic top 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belie(. <br /> Well Construction DiagramNAME PC EXPLORATION, INC ; -? <br /> (PERSON FlRM DR CORPO1tATtDN)(TYPED OR PRINTED) <br /> _. Geophysical Log(s) <br /> __ Soll/Water Chemical Analyses 178Q VERNON STREET( STE. 31 ROSEVILLEt CA 95678 <br /> Other <br /> ADDRESS CRY STATE ZIP <br /> d <br /> ATTACH ADDITIONAL 1NFORMATIOM iF iT EXISTS. Signed X_-0 e 2'?- .164.4-C6 <br /> WELL DidLLER AUTNDRIZ SFNTATIYE DATE SIGNED G57 U­ CENSE NUMBER <br /> DWR188REV.T•BO IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />