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ORIGINAL STATE OF CALIFORNIA <br /> F1161With DWR WELL COMPLETION REPORT ° <br /> Page't—of_�__ Refer to Instruction Pamphlet STATE WELL NO ISTATION NO <br /> ' Owner's Well No No 527149 ❑ C <br /> Date Work Began Ended LATITUDE LO <br /> Local Permit Agency OF <br /> J^ <br /> t Permit No Permit Date APN1TR8tcrTwR <br /> GEOLOGIC LOC WELL OW NEE <br /> ORIENTATION (r) VERTICAL — HORIZONTAL — ANGLE (SPECIFY) Name 1 0 40 <br /> ' <br /> pEPTT{FDEPTH TO FIRST W kTEB (Ft) BELOW SURFkCE 'Mailing Address <br /> ROM <br /> SURFACE DESCRIPTION l40, <br /> Ft to Ft Dercnbe mruenal,gain size color ere CITY -WELL LOCATION STATE Z Qr <br /> ' Address f .e <br /> City <br /> County <br /> JiPN Book �!9 Page_4/4_ Parcel . _ <br /> ' Township Range Section <br /> or <br /> Latitude_DEO. r MIN I DEG. MIN SEC Nam+ Longitude WE$ <br /> SEC <br /> —LOCATION SKETCHACTIVITY <br /> _✓NESN SAW WELL <br /> ' MOOIFnAT(ONIREPAIR <br /> 5�'c A <br /> L <br /> air <br /> _Other(Speeety) <br /> DESTROY(Describe <br /> ' PrxaduressedbWonai ' <br /> Undw GEOLOGCLOG <br /> PLANNED USE(S) <br /> h <br /> W I' ) <br /> ' �MONITORING <br /> i <br /> WATER SUPPLY <br /> Domest <br /> ' i + — Public� <br /> u4tiC <br /> � <br /> — avoo <br /> Industrial <br /> ' TEST WELL <br /> SOUTH — CATHOOtC PROTEC <br /> TION <br /> ----- --- - Illustrate or Desrnbe Distance of Well from 1 andmark, — OTHEIR(Specrty) <br /> such as Roads Butdings Fences Ricers etc <br /> ' - PLEASE BE ACCURATE U COMPLETE <br /> DRILLING /� <br /> — _ METHOD_ 4k-z � J!! FLUID <br /> WATER LEVEL h YIEL OF Cp41PLLTED WELL <br /> ��- DEPTH OF' STATIC WATER LEVEL (Ft) & DATE MEASURED �� <br /> ESTIMATED YIELD -(GPM) & TEST TYPE— _ <br /> TOTAL DEPTH OF BORING iFeet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL lFert) 'May not be represeman¢e of a well's Lang-term yield <br /> DEPTH BORE CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACEBORE <br /> TYPE FROM SURFACE <br /> ' <br /> DI <br /> W rr a MATERIAL INTERNAL GAUGE I SLOT SIZE �- TYPE <br /> (Inches) c� a GRADE DIAMETER OR WALL IF ANY CE BEN <br /> Ft to Ft y v m Onches) THICKNESS MENT TONITE FILL FILTER PACK(Inchesl F1 t❑ R : ) (� ) �f I (TYPE/SIZE) <br /> �C <br /> �Ald? -- d ✓ „ <br /> t '-I CERTIFICATION STATEMENT <br /> Geabpu Iqg dg <br /> the undersigned certify that this report Is COtnplete and accurate to the best of my knowledge and belief' <br /> NAA L:,nsiruci,or i}'dt7ra.r N.4 ME e rr d - — —- --- <br /> (PERSON F" OR CORPORATtpll) (TYPED OR <br /> Teophys,cal Lou(s) <br /> ._._ Sodr Water Chemrcal Analyses 57 Agn-e-I.-W <br /> .Other - AA&A <br /> AUMSS a STATE/G�/ ZIP <br />' ATTAR{ADDITDOIYAL DNFORMATIOIY IF jr EXISTS Sogried <br /> &ATIW D C 57 LICER$F N rt 6 <br /> DWR IA$REV - IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM 1 rf� <br />