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--------------- <br /> ORIGINAL STATE OF CALIFORNIA DWR USE 04LY — DO N Fl I <br /> File with DWR WELL COMPLETION REPORT ) ; 1 H �~l <br /> Page of I Refer to Instruction <br /> � n7 Pam�p]hleett STATE WELL NO/STATION NO. <br /> Owner's Well No. No. 4 U J 2 ❑ ❑ <br /> r,« Date Work Began — Ended / LATITUDE LONGITUDE <br /> Local Permit Agency 1 D bft [ �tJ1YG <br /> Permit No. Permit Date APNYTRSIOTHER <br /> GEOLOGIC LOG WELL +OWNER <br /> ORIENTATION (�) .VERTICAL ^ HORIZONTAL _ANGLE _(SPECIFY) Name 0 I r <br /> DEPTH FROM DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material,grain size,color,etc. CITY STATE ZIP <br /> D40L � WELL LOCATIaN <br /> mwash Address (aS Z S Coumfry f� <br /> f City 7a 1 <br /> r County <br /> APN Book Page Parcelor <br /> I' <br /> Township Range Section <br /> or <br /> Latitude I i NORTH Longitude I WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY <br /> NORTH <br /> LV NEW WELL <br /> MUM� I <br /> MODIFICATION IRZPAIR <br /> r —Deepen <br /> 61f" , 13vbAm ( 77 —Other(Specily) <br /> i <br /> DESTROY{Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG")! <br /> a <br /> I- PLANNED USES) <br /> Lu (r ) <br /> Lu <br /> MONITORING <br /> Q WATER SUPPLY <br /> ll, <br /> 0 <br /> FE Domestic <br /> Public <br /> -- , Irrigation <br /> f n Industrial <br /> Ca7ii>LvL T{lY CA up v 0 "TEST WELL" <br /> !!! CATHODIC PROTEC- <br /> SOUTH TION <br /> Illustrate Or Describe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> DRILLING i <br /> METHOD <br /> FLUID <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC 71�j L �] <br /> WATER LEVEL (Ft.) & DATE MEASURED vr� t <br /> ESTIMATED YIELD <br /> ' (GPM) & TEST TYPE !� <br /> TOTAL DEPTH OF BORING(Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (FO <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield. I <br /> I <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ✓ FROM SURFACE TYPE <br /> DIA. z w <br /> MATERIAL/ INTERNAL GAUGE SLOT SIZE <br /> a "` a v J GRADE DIAMETER OR WALL IF ANY CE- BEN- <br /> (inches) MENT TONITE FILL FILTER PACK <br /> F(. 10 Fl. m H �o {Inches) THICKNESS (locates) Ft. to Ft. (TYPEISIZE) <br /> b )6 1 S t(o V C A. o x <br /> t i� <br /> 01040 X <br /> ATTACHMENTS CERTIFICATION STATEMENT I <br /> Geologic Lop I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and beliel. <br /> — Well Gonelruction DiagramV NAME e �V V , YrI <br /> Geophysical LoQ(s) (PERSON, FIRM, OR C P6 TI NN) (TYPED OR PRINTED) /�,��y f Q (f J <br /> Soilt Weler Chemical Analyses O. _Box_ �( ��y„`r'T a- 5 z <br /> ADDRESS CITY STATE ZIP <br /> Other _ <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Slurped <br /> W DRILLER AUTHORI D REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> own INS REV 7-90 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM ` S 3 <br />