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OUADRUP.LICATE STATE OF CALIFORNIA D W R USE ONLY — DO NOT FILL IN <br /> . ,Fer Local Requirements 0 WELL COMPLETION REPORQ <br /> Page—of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> 11 El <br /> Owner's Well No. f s No. /� "]� Q`]i <br /> 't 1 vv ` + LATITUDE LONGITUDE <br /> Date Work Began / Ended d 1` <br /> , <br /> Local PermAgency APN/TRS/OTHER <br /> Permit No. �- •` Permit Date /r � � <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION ('�) Z VERTICAL _HORIZONTA ANGLE _(SPECIFY) Name <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE Mailing Address ( t F <br /> DEPTH FROM DESCRIPTION <br /> SURFACE CITY STATE ZIP <br /> Ft. to Ft. Describe material,grain size,color,etc. WELL L C A T I O N <br /> t Address ` t <br /> City <br /> a <br /> ' E <br /> County # <br /> APN Book Page Parcel <br /> or <br /> Township Range Section <br /> 1;. ,f, t� , / +'r ) r /� 4IV ,•c.�, w s' or NORTH Longitude WEST Latitude T <br /> DEG. MIN. SEC. <br /> DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (Z-) <br /> _ NORTH NEW WELL <br /> r <br /> — <br /> MODIFICATION/REPAIR <br /> 1 17, <br /> —Deepen <br /> —Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USE(S) <br /> U) <br /> W (—) <br /> W W MONITORING <br /> WATER SUPPLY <br /> -IQ <br /> — Domestic <br /> i <br /> Public <br /> Irrigation <br /> Industrial <br /> i <br /> r M14..........�t it ;d i } .._.......- .,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 & COMPLETE. <br /> DRILLING .. � <br /> METHOD FLUID <br /> WATER LEVEL & YIELDOF COMPLETED WELL <br /> DEPTH WATER OLEVEL— (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- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE <br /> INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. Y W o a MATERIAL/ DIAMETER OR WALL IF ANY FILTER PACK <br /> < <br /> (Inches) o GRADE MENT TONITE FILL <br /> (Inches) THICKNESS (Inches) Ft. to Ft. (� ) (� ) (� ) (TYPE/SIZE) <br /> Ft. to Ft. <br /> ' ! `4 <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(PERSON, FIRM, OR CORPORATION) (TYPED D&<PRINTED) <br /> — Geophysical Log(s) <br /> — Soil/Water Chemical Analyses ADDRESS CITY STATE ...ZIP <br /> Other <br /> Signed <br /> � � '',✓�"'..✓' �«. ... <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. SigWELL DRILI ?/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 />