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ORIGINAL STATE OF CALIFORNIA <br /> Flit with DWR WELL COMPLETION REPORT 0 <br /> page--L of--L, Refer to Instrucuan Paxrpblat STATE►'MSLL No iSTAMN No <br /> Owner's Well No _ 11tLJ -3 _ "0Date Werk Began— /A/I? Ended 527146 <br /> LArmWE ❑ <br /> Local Permit Agency LONGITUDE <br /> ' Permit No [ �,_J._, <br /> GEOLOGIC LOC Permit Date <br /> WELL 0 W N E R <br /> ORIENTATION (�} VERTICAL `_VERTICAL — HORIZONTAL —ANGLE (SPECIFY) Name 1L�1.re . �_ �_ , (�� <br /> ' DEPTH FROM nEPTN TO FIRST wnrEx (Ft) BELOW SURFACE Mailing Address 12/1 r <br /> SURFACE DESCRIPTION <br /> StLrGs <br /> Ft to Pt Describe mater I Aram rile calm,dc CITY STATE ap <br /> WELL LOCATION <br /> arve AddressIJ 116 <br /> city G � <br /> Joea <br /> County <br /> • APN Book <br /> F - -2 If Page Parcel <br /> � f <br /> Township Flange Section <br /> or <br /> Latitude NORTH Longitude wE� <br /> ' DEG MIN 5taC DEG YIiMI SEC <br /> ' <br /> LOCATION SKETCH NORTH sACTIVITY (—) <br /> _K AIEW WELL <br /> � '� <br /> / IAODIFICATIONrREPALFI <br /> ' 1Q <br /> other(Spwity) <br /> i S1 DESTROY(Dseerlor <br /> ProeedVlN andAlarerla <br /> Under CW0 LOG16Lt?G <br /> ' w PLANNED USE(S) <br /> a (!} <br /> I M6 n W MONITORING <br /> �`r WATER SUPPLY <br /> Domestic <br /> _ irngahan <br /> induarnal <br /> TEST WELL <br /> ---SOUTH — CATHODIC PRCTEC <br /> - �— Lila trate or Describe Distant, of Well from lAndmn.la _ OTHER{Specilyi <br /> such as Roads Buildings Fences Riuers etc <br /> PLEASE HE ACCURATF & COMPLETF <br /> DRILLING aw <br /> METHOD / FLUID <br /> �--� - WATER LEVEL & YIEL Ol! COMPLETED WELL <br /> ' DEPTH OF STATIC i <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> �� ESTIMATED YIELD' _ (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORTNC -----ZU (Feet TEST LENGTH (Hrs) TOTAL DRAWDOWN <br /> ' TOTAL DEPTH OF COMPLETED WELL (FI}(Feet) 'May not be representarrze aj J well r long-term xeld <br /> DEPTH BORE CaSIVC[S} ANNUL.AR %IkTER) At. <br />� FROM SURFACE TYPE ! � DEPTH <br /> HOLE FROM SURFACE TYPE - <br /> ' - QIA w W MATa RiALr INTERNAL GAUGE 3L OT SIZE - -- <br /> Ft to Fs {Incnes) �� d ' GRADE DIAMETER OR WALL_ IF ANY CE BEN <br /> Niches) THICKNESS i �F1LTE R PACK <br /> m {Inches) Ft to FF MENT TOOTH' FILL I I-f yPE SIZE) <br /> � of <br /> '-T <br /> I I T --- <br /> I <br /> AT I A( HME QTS I! y CE RTI FIICATION STATEMENT <br /> Geolog,c Log i the undersigned, certify that this report 19 COmplete and accurate to the gest of my knOwiedge and belief <br /> ' Well Construction o.agram NAME ---- -- - V <br /> GeaphYs,cai Lo4(3) (PERSON ROCK OR COM'W ) (TYPED DR <br /> Sod/Welor hem,caf Anatyaes P C t �lJrCa('� <br /> ' 1 OtherSSGTY STATE - ZIP <br /> ATTACH AI1DInONAL lA1F0RMATlON IF IT EXISTS Signed f <br /> ATIW <br /> DWR IenaeV 7 vn IF ADDITinNAI q1I is IUCCnt-n iter uevT ...,..��. _ _____ DA I LICENSE NUMBER <br />