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QUADNPLICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN <br /> Foy Local Requirements WELL COMPLETION REPORO <br /> Page Of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. //�^�J/ No. 475976 LONGITUDE <br /> Date Work Began Ended f r '_i 1 r- LATITUDE <br /> Local Permit Agency - " <br /> Permit No. I Permit Date r;' f .. APN/TRS/OTHER <br /> . GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (2!�) _L//VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER_�(Ft.) BELOW SURFACE Mailing Address •=' <br /> DEPTH FROM <br /> SURFACEE DESCRIPTION ° ;yy �' 1 ' � -°•-'' <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ZIP <br /> WELL LOCATION <br /> Address <br /> y S City t. } <br /> County 4 <br /> APN Book Page Parcel <br /> or <br /> { Township Range Section <br /> or <br /> Latitude—DEG. <br /> Longitude i WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> { J <br /> LOCATION SKETCH ACTIVITY (✓) <br /> NORTH— <br /> _,ZANEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> _Other(Specify) <br /> DESTROY(Describe <br /> ;,- Procedures and Materials <br /> Under"GEOL OGIC LOG'7 <br /> PLANNED USE(S) <br /> w w (�) <br /> 3. r MONITORING <br /> - WATER SUPPLY <br /> Domestic <br /> Public <br /> r' <br /> .. 1 Irrigation <br /> 1 Industrial <br /> R <br />' 1 <br /> - - 'f "TEST WELL.. <br /> CATHODIC PROTEC- <br /> SOUTHTION <br /> Illustrate or Describe Distance of Well from Landmarks _Z OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. - <br /> PLEASE BE ACCURATE& COMPLETE. <br /> DRILLINGMM <br /> METHOD 1)' 'E 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 BORINGi— (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) I <br /> *May not be representative of a well's long-term yield. <br /> DEPTH BORE- <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE( FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> DIA. x w o MATERIAL/ EE�T <br /> B <br /> E a oz� s GRADE DIAMETER OR WALL IF ANY TE FILLFILTER PACK <br /> Ft. to Ft. m � (Inches) THICKNESS (Inches) Ft. to Ft. ) (� ) (TYPE/SIZE) <br /> , <br /> , <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 /> .. <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTF <br /> Geophysical Log(s) I <br /> Soil/Water Chemical Analyses <br /> ADDRESS '- 4 CITY STATE ZIP <br /> Other / <br /> { ,dt <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed ��A o t ;- <br /> TEL DR�HORIZED REPRESENTATIVE DASI G D C-57 LICENSE NUMBER <br /> DWRIa8REV.7-s0 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />