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' ORIGINAL STATE OF S <br /> �. CALIFORNIA D W R E Y O 7 ILL. N <br /> File%Ith "R WELL COMPLETION REPORT <br /> Paged of Refer to Instrucnon Pampblet STATE WELL NO 15TATtON NO <br /> Owner's Well No _ M W ~ A _—•- uNn 563956 El [IDate Work Began— 77—-J5—7y Ended 7~S^9 ! LATITUDE LONGITUDE <br />' Local Permit Agency +-j ILIa t a M x at"'M C4 Y <br /> Permit No oo 32B--I Permit Date $ 1k714 I I 6PN11FISIOTH�_R <br /> GEOLOGIC LOG _ ` WELL OWNER <br /> ( <br /> ORIENTATION (`!) _VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Narver ' ` + tai r G <br />' Address sa s <br /> DEPTH FROM AEPTII TO FIRST WATER (Ft)BELOW SURFACE Mallin9 Address <br /> SURFACE DESCRIPTIONC 'Z.3 io <br /> Ft to Ft Describe material,grain size,color,etc ` CITY r } - STATE ZIP <br /> t WELL, QC T1pN <br /> t Address Z �a <br /> City <br /> County "J <br /> APN Book Page IMP— Parcel <br /> s ( Tovship �� Range Section 3 9 <br /> LatitudNORTH Longitude r l WEST <br /> y ti DEG MIN SEC DEG MIN SEC <br /> r �� <br /> LOCATION SKETCH ACTIVITY (✓) <br /> r <br /> ' k NORTH _,iG NEw WELL <br /> " ' ) MODIFICATION!REPAIR <br /> r , r <br /> Deepen <br /> - _Olher(Specify) <br /> —DESTROY(Describe <br /> Procedures andMsferfais <br /> Under GEOLOGtCLOG) <br /> PLANNED USE(S) <br /> ' Lu <br /> r <br /> t t <br /> WATER SUPPLY <br /> Domestic <br /> Public <br /> Irrigation <br /> Induatr.al <br /> TEST WELL <br /> CATHODIC PROTEC <br /> ' SOUTH TION <br /> Illustrate or Describe Distance of Weld from Landmarks —OTHER(Speedy) <br /> such as Roads Sniddings,Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br />' r " DRILLING <br /> ' METHOD FLUID <br /> WA'T'ER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) 5 DATE MEASURED <br />' 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 representative of a well's long-tent!yield <br />' DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> WTYPEi_,L FROM SURFACE TYPE <br /> DIA MATERIAL/ INTERNAL GAUGE SLOT SIZECE- BEN(Inches) GRADE DIAMETER OR WALL IF ANY MEN7 TONITE FILLFILTER PACK <br /> Ft to Ft (Inches) TTIICKNE55 {inches) Ft to Ft (TYPE/SIZE) <br /> , <br /> , <br /> ' 1 <br /> r <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 /> �Geolagia Log � �j /f ,t/ G �} <br /> Well Canslluctton Diagram NAME rvis U F atwl/t 1410} / (r�GJGe�SoA .VeA <br /> (PERSON RRM OR CORPORATION) (TYPED OR PRINTED) <br /> �, peophyatcel Logs] -+ fQJ l. �y. h(� <br /> — Sail/Water Chemical Analyses rll Ire 1JeA Foo�r�t�� i R.i- wa' ;+ � YA O. elf ?r7,9 <br /> ADDRESS CRY STATE ZIP <br /> — Olhor <br /> ATTACH ADDITIONAL INFORMATION IF IT q EXISTS Signed _�"J '• / y _ 6Y9-7 C3 p <br /> a <br /> WELL GRILLE AUTHORIZED REPRESENTATIVE DATE SIGNED C57 LICENSE NUMBER <br /> DWRieeREY 790 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM !� j <br /> t f J <br />