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CALIFORNIA ' STATE WELL 80.:511,1\ONH11 1 <br /> COMPLETION REpOR <br /> pU ADRUPLICATE wF'.LL Rele+to Instru coon <br /> ram lam— LG <br /> For L cal Re vire ^es �/ / _ / _No. 54353 LATITUDE <br /> !� Page °I �/�`I �` 2 !/�'- r^ � / J^� <br /> Owner's Well No. <br /> Date Work Began WN Films u <br /> Local Permit hCer)cY.J y �• permit Date E i G C <br /> Permit No.`�YT<` GEOLOGIC LOG ^ <br /> � ANGLE �—(SPECIFY) Name <br /> HORIZONTAL ( A4x1]ipgl AddX9�i STATE ZIP <br /> ORIENTATION (1) D VERTICAL FL) BELOW SURFACE II(j 1V <br /> DEPTH T6 FIRST WATER CII rW pll[,ds�GATI .,v <br /> DEPTH FROM DESCRIPTION <br /> SURFACE Describe material,grain Size,color,are Ft. to FL Addr <br /> City, u <br /> County <br /> y- N APN Rook Page Parcel <br /> Ems— To onshiP Range Section WES? <br /> 4' .. r NORTH Longitude SEC. <br /> Latitude�MIN. slew , <br /> � DEG. <br /> L MIN <br /> DEG. ACTIVITY (K)' <br /> L.,j LOCATION SKETCH NEW WELL <br /> i' NORTH <br /> A`( i.. E... 1 .). '1 MODIFICATION/REPAIR <br /> _Deep.- I' <br /> p Other(SPeol <br /> DESTROY(Descc/ <br /> Procedures end N <br /> Under"GEOLOG <br /> PLANNED US,� <br /> At ( 1 <br /> w µOtpTORIW <br /> A WATER SUPPLY <br /> Donee <br /> Parse <br /> Vrigati <br /> IntluaV <br /> �� •-A "TEST WEV <br /> CATHODIC I <br /> SOUTH TION <br /> Irnh.,te or Describe Ds,Fees,Well from Landmarks <br /> _OTHER(SO <br /> such as Reads,euilURA Fences,C MPP etc. <br /> PLEASE BE ACCURATE dr COMPLETE. <br /> DRILLING LUID <br /> METHOD <br /> WATER LEVE YI LDO C MPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft. 8 TEM WV <br /> ESTIMATED YIELD' (GPM 8 TEST P <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH_ (Hrs) TOT DRAWDO N (FU <br /> TOTAL DEPTH OF COMPLETED WELL (Feel) <br /> May not be representative of a well's Lang-term,yield. <br /> CASINC(S) DEPTH ANNULAR MATE; <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE SLOT SIZE <br /> DIA. W ATERIAL/ INTERy GAUGE CE- BEN- FILT <br /> GRADE DIgMETER OR WALL IF ANY EN TDNITE FILL (TV <br /> (inches) "' oG a finches) THICKNESS (Inches) Ft. to Ft. <br /> Ft. to FL ^ <br /> I <br /> it <br /> ATTAC4(vL(�.) CERTIFICATION STATEMENT <br /> I,the and rsignetl, er ty that this.report is c eantl a urate to the be of myIt owlGeoing � �ECS1 �Well CNAME(P.LRSNf k FIRMOR CO PJp�RATIDN)((T PED OR TED) J /GeophrYi y t_"�- e 1 1 E I r�. I C I (il- k l��✓ 1. ASoil/Wnalyse CITY l STATEOtM1er ?/O< ; rATTACH ADDITIONA IF IT EXISTS. Signed <br /> WELL DRILLER/ RIZED REPRESENTATIV DATE SIGNED G57 <br /> DWR IRs REV.R-Do IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />