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ORIGINAL STA rF OF ( AI[PORNIA Y — F I I <br /> File with DWR WELL COMPLETION REPORT Z S 01— <br /> Page <br /> sr '� <br /> Page_L.._ of Refer to lnriruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No No r� rtElElDate Worl. Regan_ y"�3—�7 Ended . �/�•�3-l7r_ " 3 2 8 LATITUDE LONGITUDE <br /> Local Permit Agencv.�,V TtJd956 ak*!L / <br /> P 1 <br /> Permit No Permll Biie <br /> dLOGIC LOG HELL ON IvER <br /> ORIENTATION { } VERTICAL _ HORIZONTAL _ ANGLE _(SPECIFY) Name <br /> DEPTH FROM DEPTH TO FIRSf WAIER (Ft) 1ILL.OW SURFACE Mailing Address � 4 .SOK <br /> SURFACE DESCRIPTION , e T <br /> Ft to Ft Describe material gran:size color etc CITY STATE ZIP <br /> , � WELL LOCATION <br /> Address <br /> Glty <br /> Count. isac.a <br /> APNI Boot. Page Parcel <br /> or <br /> Township Range Section <br /> or <br /> Latitude NORTH Longitude i WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> ' NORTH NEW WELL <br /> � � F <br /> MODIFICATION!REPAIR <br /> AN li� Deepen <br /> i <br /> ' Other(S eufy) <br /> i <br /> i <br /> — DESTROY(Describe <br /> Procedures and Materials <br /> ' Under GEO)OGICLOG ) <br /> ui I— <br /> —PLANNED USE(S) <br /> U) `_ [ L) <br /> MONITORING <br /> WATER SUPPLY <br /> Domestic <br /> ' Public <br /> , IrngeLon <br /> i <br /> — Industrial <br /> .40 <br /> � TEST WELL <br /> • <br /> CATHODIC PR07EG <br /> SOUTH TION <br /> ' illustrate or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rrur rs etc <br /> PLEASE BE ACCURATE v COMPLETE <br /> DRILLING <br /> METHOD ~~ FLUID <br /> H ATER 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 r:oi be reprerentanve of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE v FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> D)A 2t MATERIAL! CE BEN <br /> DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft to Ft (Inches} o w GRADE MENT T4NITE FILL <br /> m y cin (Inches) THICKNESS (Inches) Ft to Ft ( L ) (� ) (� ) (TYPE ISIZE) <br /> i <br /> e <br /> ATTACHMINTS ji) CERTIFICATION STATLMENT <br /> Geologic Lou I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> — Well Construction Diagram NAME <br /> (P RSON FIRM DR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) <br /> — SOIIlWater Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> — Other <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Slpned --- <br /> L DRILLER AU DRI REP ESENTATNE DATE SIGNED C57 LICENSL NUMBER <br /> DIAIR Ihh Itt N 7 90 IF ADDITIONAL SPACE IS NEEDED 0A NEXT CO CUTIVE-L NUMBERED RM , <br />