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QUADRUPLICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN — <br /> For <br /> NFor Local Requirements i WELL COMPLETION REPORQ I I , i , , I , I I , 71 <br /> Page—of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. J f No. I� C�']Q <br /> Date Work Began f: Ended 11 ,',• +t J e V LATITUDE LONGITUDE <br /> Local Permit Agency <br /> ~ _ APN/TRS/OTHER <br /> I Permit Date t <br /> Permit No. <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (`!L VERTICAL _HORIZONTAL _ANGLE —(SPECIFY) Name '°, <br /> DEPTH TO FIRST WATER S/�(Ft.) BELOW SURFACE Mailing Address <br /> DEPTH FROM •"} <br /> SURFACE DESCRIPTION '.t _� ' <br /> CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL LOCATION <br /> Address h <br /> - r <br /> a +' City <br /> t <br /> Ji County <br /> w APN Book Page Parcel <br /> or <br /> 1 Township Range Section <br /> or <br /> Latitude i NORTH Longitude i WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH TIVITY (2L)— <br /> NORTH <br /> ✓)NORTH 4 NEW WELL <br /> MODIFICATION/REPAIR <br /> i <br /> Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> 1 4Si Under"GEOLOGIC LOG') <br /> j 4 - PLANNED USE(S)- <br /> Lu <br /> SE(S)w 1 w ( ) <br /> 3 .�. MONITORING <br /> WATER SUPPLY <br /> ) <br /> '�dr('I Domestic <br /> Public <br /> 1 ...�....., <br /> Irrigation <br /> t <br /> }} Industrial <br /> .:TEST WELL:: <br /> ~�•~ � �������� �.:.-....__.. <br /> CATHODIC PROTEC- <br /> SOUTH /rION <br /> Illustrate or Describe Distance of Well from Landmarks __f OTHER(Specify) <br /> ' such as Roads,Buildings,Fences,Rivers,etc. ,q <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING i 1 <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 (Feet) *May not be representative of a well's long-term yield. <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- <br /> TYPE FROM SURFACE TYPE <br /> FROM SURFACE <br /> HOLE (� INTERNAL GAUGE SLOT SIZE <br /> DIA. r W o = MATERIAL/ DIAMETER OR WALL IF ANY CE- BEN- FILTER PACK <br /> (Inches) a <br /> Z. K:J GRADE MENT TONITE FILL <br /> Ft. to Ft. m N c o LL (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> i <br /> P F � <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT J <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log 1i y 1 •. tT` <br /> Well Construction Diagram NAME t IJT^`r ` �i i <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) ' <br /> Soil/Water Chemical Analyses <br /> ADDRESS YCITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. SignedWELL DRILLER/AUTHORIZED REPRESENTATIVE DA SI ED C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />