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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> ,For Local Requirements WELL COMPLETION REP ORQ <br /> Page of <br /> Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> ❑ El <br /> Well No. # ' No. a 11 <br /> Date Work Began , Ended f _ J G LATITUDE LONGITUDE <br /> i <br /> Local Permit Agency L -t- --�=Js ��ta � APN/TRS/OTHER <br /> Permit No. ._ { I ! Permit Date �,Y-�� <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (`L) VERTICAL _ HORIZONTAL ANGLE _ (SPECIFY) Name <br /> DEPTH TO FIRST WATER Y)ii ,,a(Ft.) BELOW SURFACE Mailing Address <br /> DEPTH FROM <br /> SURFACE DESCRIPTION CITY — ' ATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL LOCATION <br /> Address <br /> ' City i ) <br /> rkr i;.: County 1 r <br /> APN Book Page Parcel <br /> or <br /> Township Range Section <br /> t,,� .± Latitude i i NORTH g I <br /> de WEST <br /> LOn1tU <br /> } ') DEG. MIN. SEC. DEG. MIN. SEC. <br /> ,y LOCATION SKETCH9tCTIVITY (�) <br /> i t1 <br /> NORTH I[ NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> _Other(Specify) <br /> i <br /> " _DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> F r- PL NED USES) <br /> w a ( ) <br /> w MONITORING <br /> WATER SUPPLY <br /> I I Domestic <br /> Public <br /> Irrigation <br /> Industrial <br /> .`TEST WELL,: <br /> _ CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE 'v COMPLETE. <br /> DRILLING <br /> METHOD{'1 �t: a :' 'T t i .dlt� 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 (Feet) `May not be representative of a well's long-term yield. <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- <br /> FROM SURFACE TYFROM SURFACE TYPE <br /> PE <br /> HOLE (� INTERNAL GAUGE SLOT SIZE <br /> DIA. r z o _ MATERIAL/ DIAMETER OR WALL IF ANY CE- BEN FILTER PACK <br /> Ft. to Ft. (Inches) a U zoo J GRADE MENT TONITE FILL TYPE/SIZE) <br /> m �� J (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) <br /> N O <br /> I <br /> r} <br /> Ji <br /> I , <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <.. .. ', <br /> Well Construction Diagram NAME ' <br /> (PERSON, IRM, OR CORPORATION) (TYPED OR RINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses CITY <br /> ADDSTATE ZIP <br /> RESS��_ <br /> Other <br /> Signed <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. WELL DRILLER UORIZED R/PATE RESENTATIVE DGNED C-57 LICENSE NUMBER <br /> lkl <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEE D, USE *EXT CONSECUTIVELY NUMBERED FORM <br />