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's71i1<air9AL ST'Afr IF' CALIFORNIA ' .• DWR SE ON Y — N T FILL IN <br /> File with DWR ` WELL ION REPORT 1 <br /> Page t of .-f Refer to Instruction Pamphlet STATE WELL NO.I STATION NO. <br /> Owner's Nell Into. MWS � Z 3 s No. 532001 <br /> ❑ � <br /> Date Work Began t r Ended LATITUDE LONGITUDE <br /> Local Permit Agency J (Y1t cS� <br /> Permit NO. Permit Date APNITRS/ TH R <br /> GEOLOGIC LOG P4'ELL OWNER <br /> ORIENTATION (:L Q VERTICAL "HORIZONTAL _ ANGLE —(SPECIFY) Name IDOII'e PQ�_-Y'a 121�,A4 <br /> oEP7H FROM DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address -, <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. ,Describe material,grain iize,color,etc CITY STATE ZIP <br /> WE L tQCATION <br /> Address 13 <br /> E4,,ID i+rt 2 <br /> r , <br /> r Cite C4.. <br /> Counts <br /> I it <br /> APN Boot: Page Parcel <br /> I Township <br /> or <br /> I r LatitudeNORTH Longitude WEST <br /> y"Y DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH <br /> NORTH ACTIVITY (✓) <br /> ' Z NEW WELL <br /> ' MODIFICATION I REPAIR <br /> r <br /> r <br /> I / Deepen <br /> Other(Specify) <br /> I � <br /> r <br /> DESTROY(Describe <br /> Procedures and Maferiafs <br /> t r <br /> Under••GEOLOGICLOG') <br /> VAA <br /> a -PLANNED USE(S) <br /> LIj <br /> ' MONITORING <br /> r r <br /> ' WATER SUPPLY <br /> t , <br /> r I — Domestic <br /> 1 t <br /> — Public <br /> �2 Q <br /> , r Irrigation <br /> V t <br /> r <br /> Industrial <br /> r — ..TEST WELL.. <br /> CATHODIC PROTEC. <br /> t SOUTH TICK <br /> Illustrate or Describe Distance of Well front Landmarks _ OTHER(Specify) <br /> such as Roads.Buildings,Fences,Ricers,etc. <br /> PLEASE BE ACCURATE & CONIPLETE. <br /> DRILLING <br /> METHOD FLUID <br /> ' WATER LEVELF OF LETED WELL <br /> DEPTH OF STATIC <br /> t <br /> WATER LEVEL ATE MEASURED <br /> ESTIMATED YIELD' (GPM) d TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH rs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feel) 'May not be esentative of a well's Fong-terra yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> HOLE SURFACE HOLE TYPE FROM SURFACE TYPE <br /> INTER GAUGE SLOT SIZE <br /> (IDh <br /> A. <br /> a ¢ o� MATERIE/ TER OR WALL IF ANY 7ETTON TE FILL ER PACK <br /> BI <br /> Ft. to Ft. m h c (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEtSIZE) <br /> fes) (� <br /> I <br /> ATTACHMENTS (!I CERTIFICATION STATEMENT <br /> Geologic Log I, the undersigned,cer ty that this report isCo plete and accurate to the best of my knowiedg= an^ r l-ef <br /> rr , <br /> Well Construction Diagram NAME w, r Of' Y� (`_--Vs. � f�{ <br /> (PERSON, FIRM. OR CORPORATION) (TYPED OR PRINTF <br /> Geophysical Logs) P Q� �,�//� 1�//I [ 5 <br /> Sa,, Water Ch micat Analys?.; " o //tl�o 36 (� • ,. L � 4�✓� f <br /> Y n anOREs ,' �)rr'1 ?ITV STA77 I <br /> ' r- •y :Art Ni :'Ntiftr „t7n Re' .•n -' , r. _ <br /> WEL.. DRILLERADTHORIZEC REPRLSr.Ivf?�;r'. _ DATE SIGNEE <br /> `411MRFH� ­ Rt., - .. <br />