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DWR USE ONLY — DO NOT FILL IN <br /> STATE OF CALIFORNIA <br /> QUADRUPLICATE WELL COMPLETION REPORI , STATE WELL NO./STATION NO. ❑ <br /> al Req Irements \� Refer to Instruction Pamphlet ❑ <br /> For Loi of PA ( <br /> No. 5 5 4 3 5 4 LONGITUDE <br /> Page—l+- I � 1y �"'"% Vt LATITUDE <br /> Owner's Well No. 2,v Ended { /�,} <br /> " ) APN/TRS/ TH R <br /> _ Date Work Began L,�- <br /> Local Permit�Ia Permit Date c 1� L OV�:NE <br /> 1'erulit No. 1'� 4 V j <br /> GEOLOGIC LOG --ANGLE (SPECIFY) Name Al ( -7 1 <br /> 11 r <br /> ORIENTATION (�) _ VERTICAL HORIZONTAL <br /> F[ BELOW SURFACE IVI lhM Ad KA u 7"- <br /> DEPTH TO FIRST WATER— --( ) A Irl STATE zIP <br /> DEPTH FROM DE,SCRI PTION aTY } �� <br /> SURFACE <br /> Describe material,grain size,color,etc. I <br /> Ft. to Ft. Addres <br /> CityIt <br /> , <br /> County <br /> APN Book -� Page Parcel <br /> °fRange Section <br /> Township WEST <br /> EG <br /> or NORTH Longitude D . MIN. SEC. <br /> Latitude MIN. SEC. <br /> DEG. ✓ <br /> , ACTIVITY (—) <br /> LOCATION SKETCH <br /> ' j _ � NORTH _NEW WELL <br /> 'T ` I <br /> � 4✓4 ..%�..� � � /'� y f 1 � /, � y^ MODIFICATION/REPAIR <br /> Deepen <br /> Other(SpecifY) <br /> i d d <br /> DESTROY(Describe <br /> It Procedures and Materials <br /> ' }.". ......— ,-L- Under"GEOLOGIC LOG") <br /> 1` PLANNED USE(S) <br /> r~n w MONITORING <br /> w <br /> i WATER SUPPLY <br /> Domestic <br /> i <br /> � Public <br /> i Irrigation <br /> Industrial <br /> � "TEST WELL" <br /> CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate or Describe Distance of Well from Landmarks <br /> OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE G COMPLETE. <br /> DRILLING FLUI <br /> METHOD <br /> ' WATER LEVEL & YIEL O C PLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.) & DATE EAS D <br /> ESTIMATED YIELD* (GPM) & ST TYP <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.) TOTAL AWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield. <br /> CI (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE_ FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE <br /> r W i MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> DIA. <br /> DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. (Inches) < J GRADE (Inches) THICKNESS (Inches) Ft. to Ft. (✓ ) (✓ ) (✓ ) (TYPE/SI E) <br /> m <br /> e l etc I <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> I,the undersigned,cert' that this report' mplete a d accurate to the best my knowler ge and belief. <br /> Geologi Lo r (1 f�(� G__ ty-f f t_ - Il <br /> Well Co tion Di gram NAME11 / <br /> �� ( (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log( rr^ r T T �f <br /> Soil/Water Che ca s —T / r�-�'�'r u �,l FT `�G1 <br /> ADDRESS -+ CITY STATE ZIP <br /> — Other <br /> ATTACH ADDITIONAL /NF MAT/ON. IF IT EX/STS. Signed WELL DRILLER/ ORIZEREPRESENTATIVE <br /> DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV,7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY'NUMBERED FORM <br />