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�l ORIGINAL STATE OF CALIFORNIA — H -- <br /> FIILO +fifth DWR WELL COMPLETION REPORT 10_1215 1 a 7 01�J'Aj I III <br /> Page L Of-L Refer to Irtttructiort Parrtpblet STATE WELL NO/STATipN No <br /> Owner's Well No - 2 _ N7o 5 2? 14 4 <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No Permit Date r APNITRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (! ��VERTICAL — HORI;OWAL ` ANGLE ,(SPECIFY) Name 6r,0---,P .� <br /> ' DEPTJ�tSURFROMFACE DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mulling Address o <br /> DESCRIPTIONA/� �f <br /> 7 <br /> Ft to Ft Dermbe matowl,gram nze color etc CITY STATE ZIP <br /> rn -W 'LL LOCATION <br /> �` Address lwl"f <br /> ' -� city_"4&4; se <br /> f County <br /> 7APN Book.;?/!fPage l Ld Parcel. - 1 I <br /> ' — Tow«scup Range Section <br /> A11- <br /> Aid <br /> Latitude t I SEC tJORT}7 Longitude DEG MIN SEC WEs <br /> ' DEG MIH <br /> LOCATION SKETCHt1�TIVITY (�} <br /> NORTH NET WELL <br /> 1 w <br /> MODIFICATIONlREPAIR <br /> v <br /> ' Deepen <br /> Other(Specify) <br /> —DESTROY(Oest:n6e <br /> i Procadwee and Ahfarla <br /> Under GEOLO=LOG <br /> PLANNED USE(S) <br /> ' 3 w 1/ (f) <br /> — MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> Pupiic <br /> irripahon <br /> -- tnriustrlal <br /> ' - - - - -- TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH- - - - TION <br /> -- - fllustrate ar Descrrbe Distan- of V ell frum Caln+lmar.. OTHER(Sgec,ly} <br /> such as Roads Buildings Fences Rivers etc <br /> -` -� - - PLEASE BE ACCURATE & COMPLETE - <br /> DRILLING <br /> _ METHOD Il.,16i tJG FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF ST.A 1 F <br /> ' -- --- WATER LEVEL (Ft) & DATE MEASURED L/ T <br /> ESTIMATED YIELD (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING 4) __ (F.t)A TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTI{ OF COMPLETED WELL (Deet) 'May not be representauve of a wel!'t Amg-term yield <br /> DEPTH CASINGS) ANNLLaR NIATERIAS. <br /> FROM SURFACE HOLE -- -- DEPTH i <br /> TY-7-rFROM SURFACE TYPE <br /> INTERNAL <br /> ' DIA ktATERJAL GAUGE SLOT SITE -GRADE OIAMETERI OR WALL iF ANY CE BEN FILTER PACK <br /> Ft to Fi (inches) THICKNESS (IncA6s} Ft to Ft MENT TDNM F'LL I {�) {�) I�} (TYPE/SIZE) <br /> it [_ry <br /> kTT 1CH4ILVTS I 1 CERTIFICATION STATEMFNT <br /> the undersigned certify that this report iB�Cornpiete and accurate to the best of nv AI'flwfedge and Defret <br /> [iePIPfJ+C�)5} <br /> ' <br /> Well Conatruchun Diagram NAME - <br /> Geophysical Log(S) <br /> rPEASUR FIRM OR CORPORATON) (TYPED ' TEA-) <br /> _ S-� F,041 Water Chemical Analyse, -- 14 'of 5oa� <br /> RFS C STAT;: T <br /> Other .�-���OOO��'///ZIP <br /> ' ATTACH A001770NA1_ INFORMATION 1F rT EXISTS Signed �2 <br /> L ATIVE SU ED <br /> C LICENSE NUMBER <br /> owH 188X1•V -+w IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM / / <br />