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QUADRUPLICATE STATE OF CALIFORNIA R t Y — N T <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page—�Of—� Refer to Intbuction Pampblet STATE WELL NO./STATION NO. <br /> OWirme,R'ell N6 No. C C O� �� ���—� —� <br /> Date Work Began , Ended 57 J v uTRGDE ❑ Lo-` NcrtuoE�❑ <br /> Local Permit Agenccy7 1779?—) - , ^-o / f <br /> Permit No. Permit Date AFNAAW. <br /> :IDYGEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!) A. VERTICAL _ HORIZONTAL _ANGLE _(SPECIFY) Name _ <br /> DEPTH FROM DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing dress <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Deteribe Tmaterial,grain liu,color,etc. CK40her, clSA - <br /> . <br /> WELL LOCATION <br /> c <br /> Address M<areeria I. C1r1 <br /> 4 10 Sandy Clay City MalnfetCS <br /> 10 57 ; SAnd County `rmd <br /> 8 t7&0.)i n <br /> 57 90 Clav APN Book Page Parcel <br /> - 93 SRnd To unship Range Section <br /> 93 1 Latitude DEG, I MIN. SEC. NORTH <br /> OEG. esT <br /> Longitude wMIN. SEC. <br /> 139 51191�19 t, LOCATION SKETCH ACTIVITY (')— <br /> . NORTH NEW WELL <br /> 145 147 sand <br /> 147 far" <br /> - MODIFICATION/REPAIR <br /> � 155 � !''I,tTli `++tg RrA.i <br /> 255 17 C1aev Deep.. <br /> 170 <br /> _On.(Specify) <br /> '8Et ' :s' n <br /> DESTROY(Oeacaba <br /> Preced.if and Mat-dela <br /> Under"GEOLOGIC IOU") <br /> m y PLANNED 3 USE(S)- <br /> w �) <br /> MONITORING <br /> WATER SUPPLY <br /> Dpna6liC <br /> Public <br /> Irrigation <br /> Inaustrial <br /> "TEST WELL" <br /> SOUTH TION CAT­lODIC PROTEC <br /> Illustrate or Describe Distance of Well from Landmarks _ OTHER(Specify) <br /> such w Roads,Budding.,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE 6 COMPLETE. <br /> DRILLING <br /> METHOD ROTARY FLUID WATER <br /> WATER LEVEL ,I YIELD OF COMPLETED WELL <br /> . . DEPTH OF STATIC <br /> WATER LEVEL 10 (Ft.) A DATE MEASURED <br /> ESTIMATED YIELD' (GPM) A TEST TYPE <br /> TOTAL DEPTH OF BORING I AR (Feef) TEST LENGTH_ (Hca.) TOTAL DRAWDOWN (FtJ <br /> TOTAL DEPTH OF COMPLETED WELL 1 fo� (Feet) "May not be representative of a well i long-tern+peld. <br /> DEPTH CA SI NC(S) DTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> DIA. W "' MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN <br /> (Inches) DIAMETER OR WALL IF ANY CIE. TSEN. FILL <br /> Ft. to Ft. � s GRADE (Inches) THICKNESS FILTER PACK <br /> c�. _ (Intoes) Ft. to FL (TYPE/SIZE) <br /> x 100 lot L <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> Geologic Lop 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Wall Construction Diagram NAME -t1A"V& L. la DR1G.I. halts. INC _ <br /> — Geophysical Leg(a) (PERSONv, FIRM. OR CORPOfUtION) (TYPED OR PRINTED) <br /> — Soil/Water Chemical Analyses 119 Al{' ar Rd I.f,( deeto CA 9S31S7 <br /> _ Other ADDRESS CITY STATE ZIP <br /> n' <br /> ATTACH ADDITIONAL INFORMATION. IF/T EXISTS. Signed " I 01115197 64r,8622 <br /> WELL'MILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED G57 LICENSE NUMBER <br /> DWR Ins REV 7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />