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QUADRUPLICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REP( 1116 1, . 111 111 111 1 1 <br /> Page of f Refer to Instruction Pam hlet r 1 STATE WELL NO./STATION NO. <br /> Owner's Well No. � ' No. A 7 Q /� ❑ ❑ <br /> Date Work Began �i rf "; � k.. Ended /f •' `f LATITUDE LONGITUDE <br /> J <br /> Local Permit Agency <br /> i 1 <br /> Permit No. ° Permit Date > i' APN/TR /OTHER <br /> GEOLOGIC LOG 4W. LL OWNER <br /> ORIENTATION (`�) VERTICAL _ HORIZONTALANGLE _(SPECIFY) Nage <br /> DEPTH TO FIRST WATER 'r I�� (Ft.) BELOW SURFACE Maim Ac}d ss n <br /> DEPTH <br /> P HH FROACEM DESCRIPTION <br /> CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. <br /> WELL LOCATION <br /> I t <br /> i y Address f <br /> Cit j t <br /> I I <br /> County t <br /> APN Book Page Parcel <br /> Township Range Section <br /> Latitude I I NORTH Longitude, i WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (.!L) <br /> NORTH /NEW WELL <br /> dJ MODIFICATION/REPAIR <br /> _Deepen <br /> _Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> f Under"GEOLOGIC LOG') <br /> 1 PLANNED USE(S) <br /> ul €€€ <br /> MONITORING <br /> I ' <br /> WATER SUPPLY <br /> I I ~ Domestic <br /> Public <br /> _ Irrigation <br /> I I <br /> Industrial <br /> ......L.,,,,.L.....,.. "TEST WELL" <br /> SOUTH _/ <br /> CATHODIC PROTEC- <br /> T <br /> Illustrate or Describe Distance of Well from Landmarks OTHTIONER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE it COMPLETE. <br /> I I <br /> DRILLING 4;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 'I," (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- FROM SURFACE TYPE <br /> FROM SURFACE HOLE VTYPE2_�LDIA. MATERIAL/ INTERNAL GAUGE SLOT SIZECE- BEN- <br /> DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) MENT TONITE FILL <br /> GRADEFt. to Ft. (Inches) THICKNESS (Inches) Ft. to F4. (TYPE/SIZE) <br /> (—' ) <br /> l I <br /> , I r <br /> ATTACHMENTS (✓) - CERTIFICATION STAT MENT <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, FIRM, OR CORPORATION) (TYPED OR- TED) <br /> Geophysical Log(s) - ! - <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other 1' <br /> r <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. SignedWELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />