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ORIGINAL 'iTArE OI• (ALH ORNIA w R USE ONLY — DO NOT FI ,N <br /> File with DWR WELL COMPLETION REPORT _j.__L l I_ i__L I I I <br /> Paget of Refer to Instruction Parnpblet STATE WELL NO ISTATION NO <br /> Owner's Well No ^ 7' NO 495640 <br /> Date Work Began iZ Ended 14,4-3 LATITUDE LONGITUDE <br /> Local Permit Agency Q r r <br /> Permit No Permit Date t I I $r143 <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (.!!L) RTICAL —HORIZONTAL — ANGLE _, (SPECIFY) Name Z SC!! 0?, <br /> DEPTH TO FIRST WATER 20 —9 (FL) BELOW SURFACE Mailing Address ZS 5O N o l.00 p LJCS`4 <br /> DEPTH <br /> EURFACEM DESCRIPTION HoQMtQ,� �.... TyC 77691 <br /> Ft to _Ft Describe materia! dram CITYsize color etc W Ll' STATE ZIP <br /> LOCA TION <br /> Address „ICD 1.z:.._„ -A yr— ' <br /> rt��t-e ca, <br /> City .— <br /> County <br /> APN Book Page Parcel <br /> Township 5 Range Section <br /> or <br /> Latitude NORTH Longitude_ I wFsr <br /> ' DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (!) <br /> NORTH NEW WELL <br /> f MODIFICATION!REPAIR <br /> `' (�� <br /> T O SQ�Yl —Deepen <br /> ' 7 Other(Specify) I <br /> DESTROY(Describe <br /> Procedures and Materia. <br /> Under GEOLOGICLOG)I <br /> NPLANNED? USE(S) <br /> LLI <br /> a (—) <br /> � IL MONITORING i <br /> ' WATER SUPPLY I <br /> _ Domestic ( <br /> ' 1 Public <br /> Irrigation I <br /> I <br /> Industrial I <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Ruildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPI ETE <br /> DRILLING HO'L 10 W^ /A <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & 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 _23--5—(Feet) May not be represenaaime of a-well's long-terra yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE � FROM SURFACE TYPE <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> DIA z z a MATERIAL/ CE BEN <br /> (Inches) x w x� GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft t0 Ft m �� J (Inches) THICKNESS (Inches) Ft to Ft MENT TONITE FILL <br /> (TYPE/SIZE) <br /> PQ O O 10 <br /> vc, 2- SCH401S t0Z <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> 4410 r Z Geologic Log <br /> I,the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> (, l / /� <br /> — Well Construction Diagram I NAME i t dr© F-�)i rQr)�jn � f Q ` CSCS., L_, <br /> } ` ^OPER FIRM (U (TYPED <br /> OR PRINTED))}' �] l ��}/y`/� /moi Q/� <br /> i Geophysical �`..]�� { \Qr,kt �C_+\ Sa "" Er� 1QiwC.I. CL [ ('AL L !! <br /> — So,)/Water,Chemical Analyses 4 <br /> , ADDRESS C 1 0QA,�STATE ZIP Q <br /> Other " �I I � <br /> � Ii,l I � <br /> E ATTACH ADDITIONAL'INFORMATION IfF iT,exos;TS E 4 Signed WEEL pRILiER THO RESENTATI i I I ' I f ' 't DATE SIGNED I I, C 571 LICENSE NUMBER <br /> I I! <br /> l DWR 188 REV;90 I IF ADDITIONAL SPACE iS NEEDED IUSF NEXT CONSECUTIVELY NUMBERE Di`FORM, <br />