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TRIPLICATE STATE OF CALIFORNIA DWA USE ONLY — N T FI IN �• <br />' Owner's Copy WELL COMPLETION REPORT_ STATE WELL NO STATION IND <br /> Page _of Refer to InssTucfron Pamphlet <br /> Owner's Well No �"t �� No 554306 <br /> Date Work Began _ ��Gam_ Ended LAnruos LONGITUDE <br /> Local Permit Agency e ^ ~ — ' `4 <br /> t Permit No U Permit Date I <br /> APNiT'R <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) £RTnCAL — HORIZONTAL ANGLE �-(SPECIFY) Namet + ' i+ <br /> DEPTH TO FIRST WATER/I—,- !:!��(FL) BELOW SURFACE Mailing Address ~ <br /> DEPTH FROM -4 r 1. : `y y�\/ <br /> SURFACE DESCRIPTION - <br /> Ft to Ft Describe material grain n:e color etc -, t CITY i'� , t Z T TAT ZIP <br /> � � � WELL,`LOCATION <br /> 1 <br /> � { Address` f .� r• <br /> City. 1; 1 ;1 -- <br />' _ 'F County � r t <br /> 4 1. - I I r r "PN Book Page Parcel <br /> or <br /> ' I) t _ Township N1 Range��Section�� �— <br /> or <br /> r r ` Latitude 1 NORTH Longitude w£sr <br /> ' rr r �r � , e� / _ DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (!) <br /> L 1 ice` ;` ' ♦ i r NORTH WELL <br /> a `� Z f ```t t�T MODIFICATMJ REPAIR i <br /> � 1 � ��• �Y�v � "I �..!�� �r �+W� � _Deepen <br /> WNt J.. I'~1 A /r c f Other(Specly) <br /> ' � r <br /> ' (• t ' ^ v YAC r _�DESTROY(Describe <br /> �� <br />' 1 t �- _ .. e,H,, Procsdur"and Materials <br /> 1 h'\`_� J e� ` Under-GEOLOG7CLOG) <br /> G, PLANNED USE(S) <br /> + _ t 1� }aMy s•' _ `�. J s I <br /> W n n i - ..�+^� uj ~MOWrORING WATER SUPPLY <br /> l <br /> Domestic <br /> Public <br /> Irrigation <br /> , <br /> 6tduatrial <br /> r __ 'TEST WELL <br /> ` CATHODIC PROTEC <br /> SOUTH -710N k, <br /> 1 1 Iffustrata or Describe Distafue of Well from LaOTHER(Specify) <br /> f, such as Roads Buildings Fences Ritim etc. _ r <br /> PLEASE BE ACCURATE & COMPLETE. <br /> Y <br /> METHOD + <T3'i -- FLUID J <br /> WATER LEVEL a YIELD OF COMPLETED WELL <br /> 1 DEPTH OF STATICr <br /> WATER LEVEL (Ft) d DATE MEASURED / <br /> 1 ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING �yx�(Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL CAA.ir— (Feet) 'May not be representative of a well's long-terra yield <br /> CASING(S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE � <br /> DIA r m INTERNAL GAUGE SLOT SIZE <br /> MATERIAL/ CE 8EN <br /> (inches) _� d DIAMETER OR WALL IF ANY ME TDNITE FILL FRIER PACK <br /> Fi to Ft m $ _ GRADE Onches) THICKNESS (Inches) Ft to Ft (� ) (TYPE/SIZE) <br /> N <br /> 1 ' l L L" _rJAAAf <br /> l+ ' ) fc II -1 ' <br /> e 1 r <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log I the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br /> 5 <br /> -. Well Construction Diagram NAME 14 Lf� <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) S! {.�G�.. j r <br /> SolEl Water Chemical Analyses IP <br /> AppR $$ CITY STATE <br /> Other <br /> ATTACH ADDITIONAL INFORMATION IF fT EXISTS Sepne y S p C57 LICENSE NUMBER <br /> LL KIPAPIORLM <br /> DWR 1MBE% 7 90 IF ADDITIONAL SPACE IS NEEDEr USE NEXT CONSECUTIVELY NUMBERED FORM <br />