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ORIGINAL SrATF OF ( 11 IFORNIA OW El USE 0 — T F I N �- <br /> File with DWR WELL COMPLETION REPORT <br /> Page_L of_L_ Refer to lnirrutnpn Pamphlet STATE WELL NO 7STATION NO <br /> Owner's Well Nop <br /> No <br /> t Date Work Began 14 3 Ended I Z�4 IQ3 LATITUDE ❑ LONGITUDE E <br /> Local Permit Agency Solr-, J c a4y i n cgtj r +y Pu bl iC. 4-M <br /> Permit No I -k9-7PDate l i t /93 ' R <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (tVERTICAL — HORIZONTAL ANGLE _(SPECIFY) Name S V , <br /> DEPTH TO FIRST WATER2_9�S(Ft) BELOW SURFACE Malting Address_2550 N o LQQ e's+- -ii- <br /> DEPTH FROM 779 <br /> SURFACE DESCRIPTION <br /> L <br /> Ft to Ft 17ercrrbe rrtatenal grain size color etc CITY WELL � QCATION STATE ZIP <br /> Address I O l Z. LA] Y S ems%t te. Ai)e_ <br /> 1 , City <br /> County `, <br /> APN Book Page Parcel <br /> or <br /> Township 2S-- Range Section <br /> or <br /> Latitude_ NORTH Longitude I wEST <br /> DEG MIN SEC DEO MIN $EC <br /> LOCATION SKETCH ACTIVITY <br /> NORTH ` ✓NEW WELL <br /> 1 , � <br /> Vo:5 <br /> P/+tr1 - t MODIFfCATON/REPAIR <br /> .J� —Deepen <br /> _.,Other(Specify) <br /> DESTROY(peacn6e <br /> C,1��cn Prxedurea and Matenets <br /> 1 is P Under GEOLOGICLOG)i <br /> r PLANNED U5E(5) <br /> LLI <br /> I I <br /> w _ MONITORING i <br /> ` n0oif <br /> WATER SUPPLY <br /> U <br /> DomeaLc <br /> CU <br /> Publle I <br /> 1 , Irrigation i <br /> Industrial <br /> TEST WELL <br /> Tart u <br /> _CATHODIC PROTEC , <br /> SOUTH TION I <br /> Illustrate or Describe Distance of Well from Landmarks _ OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc t <br /> PLEASE BE ACCURATE ds COMPLETE <br /> METHOD <br /> I tow r r, - A <br /> 1 METHQD FLUID -- <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> 1 ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING RC2(Fee TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not he representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE WTYPE _*� FROM SURFACE TYPE <br /> HOLEINTEERNAL GAUGE SLOT SIZEDIA MATERIAL! DIAMETER OR WALL IF ANY CE 8EN <br /> GRADE MENTTOINITE FILLFILTER PACK <br /> (Inches) (TYPE/SIZE) <br /> Ft to Ft (Inches) THICKNESS pnches) Ft to Ft (� ) (f ) (✓ ) <br /> p y 4 5 X V P o i o "x 11 <br /> 4 U z 00/0 i(n I X <br />� � I12, I <br /> , <br /> I <br /> I 1 + I 1 1 I I I 1 I 1 <br /> ATTACHMENTS '(!] CERTIFICATION STATEMENT <br /> 1 h I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geo(og,c Loud m- <br /> Wel!Construction Diagram NAME I ---- <br /> (PERSON FIM 0 TI (TYPED DR PRINTED) <br /> �.. Geophysical Log(s) (�Qr iM � � ^*STATE <br /> � n <br /> SOIU Water Chemical Analyses f•\ { a `� <br /> I ADDRESS CITY /f QZIP/� Q <br /> lI` Other 1 II,I 1 I I 1 1 12/217 `7 I 15 I 1-1 C_J.] ' <br /> ATTACH A=VT NAt INFORMATION I IF,iT EXISTS I Stp���WELL DRILLER/ I ED REPRESENTAT I I 4 l�I I I it 1 �4 I'DATE SIGNED I 'I <br /> Y C 57 LICENSE NUMBER I <br /> T)w>iiSrlRsv117aD';'lII X11'IF=IADDITIONALiISPAGEIIS�NEEDED,.USE NEXT CONSEC071VELYINUMBERED�FORM,i I1 <br />