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ORIGINAL ) <br /> STATE OF CALIFORNIA DWR U E ONLY — D O D F I L i <br /> File with DWR WELL COMPLETION REPORT <br />' r Page--*L of Refer to Ivirructlon Parrrpblet STAYff WELL NO/STATION NO <br /> Owner's Well No M w 3 No 7D <br /> Date Work Began �"6-711 Ended 7-6-?141 LATITUDE LONGITUDE <br /> Local Permit Agency 9A L11 t-06 hten+o, ] '�-fQA44trn.th lV P +tite ' <br />' <br /> PermD3I APN! S OTHER <br /> Permit No _ �a 3 e? 3 uZ Permit ate— ^gy <br /> GEOLOGIC LOG ` <br /> o/-/-,.-. WELL OWNER <br /> ORIENTATION (.!L) VERTICAL .—._HORIZONTAL — ANGLE (SPECIFY) Name Ub l ~F <br /> DEPTH FROM DEPTH TO FIRST WATER {Ft)BELOW SURFACE -Mailing Address`s � 1' f <br /> SURFACE DESCRIPTION \ - F� Y "C 3Z3� <br /> Ft to Ft Dercrebe maternal to ttze,calor,etc CITY STATE ZIP <br /> s WEL G ION <br /> ` z 3;S`o <br /> J Address <br /> ty <br /> County <br /> ` APN Book � =Parci <br /> ` Township__2 N Range 6 Section G <br /> r Y l Latitude NORTH Longitude r s WEST <br /> I i <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH �A�CTIVITY {✓) <br /> NORTH _IC"C T.WELL <br /> _ MODIFICA710Nf REPAIR <br /> I ,f _Deepen <br /> —Other(specify) <br /> DESTROY(Describe <br /> ProceduressadMaterfals <br /> Under GEOLOGICLOG 7 <br /> r r <br /> to PLANNED USE(S) <br /> Lu <br /> , r MONITORING ! <br /> I WATER SUPPLY <br /> I , <br /> _ Domestic <br /> r Public <br /> r <br /> r Irrigation <br /> i <br /> , <br /> ladusirlel <br /> r , TEST WELL <br />' CATHODIC PROTEC <br /> ' SOUTH TION <br /> r Illustrate or Describe Distance of Well from Landmarks OTHER(specify) <br /> such as Roads Buildings Fences Risers etc <br /> r PLEASE BE ACCURATE& COMPLETE <br /> . r <br /> DRILLING <br /> r � METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> r I DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br />' ESTIMATED YIELD` (GPM) A TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representatme of a well's long-terns Weld <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE <br /> TYPE <br /> DIA '� MgTkilAL! INTERNAL GAUGE SLOT SIZE <br /> Ft tp Ft (Inches) 5 on M GRADE DIAMETER OR WALL 1F ANY MENT 70NITE FILL FILTER PACK <br /> v _� (Inches) TH)CKNESS (laches) Ft to Ft <br /> m y c ( J ) (,L ) (TYPE/SIZE) <br /> r , <br /> r � <br /> , I <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> I the undersigned,certify that this report Is complete and accurate to the best of my knowledge and belief <br /> AL-'weir <br /> CIC Lop ''�1 /� /� �,/ /� <br /> �! WeII Canstructlon Dragram NAME I O ri�_� L)F`O W11 17r-fOA` / F t`C ICif SDA 1/.n���IF1 I� A G_ <br /> �� Gaophys7oal Log(s) <br /> (PERSON FIRtA OR CORPORATION) (TYPED OR PRINTED) <br /> f� ,&/7} p <br /> Soft/WaterChem,cal Analyses Gp den rpeTR+ I � kwt ` I ✓ar_Mj1f> 17r1!! IS-76 <br /> Other ADDRESS r CITY STATE � ZIP <br /> z <br /> ATTACH AODITrONAL INPORMATION IF IT f_XIST5 5epne1 ' S_S 91V` b SS 7 S6 <br /> WELL DRILLER AUTHORIZEI REPRfSENTAT1Vk DATE SIGNED C57 LICENSE NUMBER <br /> DWRte8REV Asa IF ADDITIONAL SPACE IS NEEDED USE NEXT OONSECUTIVELY NUMBERED FORM r� T <br /> 4 d • <br />