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ORIGINAL STATe OF CALIFORNIA <br /> File with DWR WELL COMPLETION REPORT L it N °1 b ' to N <br /> Paage. -�-.of A Refer to Inttruceiort Panrpblet STATE WELL NO.ISTATION NO. �—} <br /> ' Owner's Well ND. W"' _ _ No, C L 1 <br /> Date Work Aegan , Ended <br /> 't ® LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No.Q� +�, ?�,.. Permit Bate =jPN1TRS1OTMFI <br /> � J GEOLOGIC LOG WELL 0 ER <br /> ORIENTATION ( ) /'VERTICAL HORIZONTAL __ANGLE ,—,_(SPECIFY) Na ' <br /> ' <br /> DEPTH FROBFPTI1 TO FIRST 1VATER (FL)BELOW SURFACE IViaif1jg Addrri -_ss d- U 1 M �.._ . <br /> SURFACE DESCRIPTIQN '.�I I "�i1 T` �� 7h 4 <br /> FI. to ZIP <br /> Ft. Describe m CITY srnr eriat,Rrartt rfze,talar,etc, •. <br /> _, <br /> WELL LOCA ION <br /> ' n Andress— 'Tj�j S. <br /> City <br /> lcounty— <br /> APN Book Page Parcel a"o <br /> Township,—Range Section <br /> ' <br /> 1 1 pr i .L:tHt'uile_ � 1 NORTH LongitudeASJIIWCST <br /> DEC). MIN. SEC. DEG. MIN. SEC, <br /> f LOCATION SHETClI VITY (!) <br /> ' NORTH VNEw WELL <br /> r 1 MODIFICATIONIREPAM <br /> Y M1* <br /> Deepen <br /> r <br /> Other(Opdcily) <br /> r 8 � ProeeduraeandMaterrala <br /> ' ' q under"SEOL0M0L0d'7 <br /> PLANNED USES) <br /> +1 <br /> ' 1 �} \OrJti.�r, Sf�� � <br /> t MUNITORINA <br /> WATER SUPPLY <br /> J Ct .—, Doroeella <br /> PUbIIc <br /> 1 1 <br /> ' IrngMllan <br /> 1 I <br /> 1 IndusUial <br /> 1 r <br /> , 1 <br /> CATHODIC PROTEC• <br /> SOUTH TION <br /> 1 1 Riustrate or Describe Distanceuce of Well frarn Landmarks .,^... oTtrEss(spacirr) <br /> such as floods.Rnddings,Fences,Rivers,etc. <br /> PLrASE BE ACCUR iTC&DRILLING G'OV[TLDTR. <br /> � ar <br /> METHOD-. I l/J 1"� {� FLUIp 6 <br /> ' r WATER LEVEL YIELY OF CONIPLE )?DNY-ELL <br /> DEPTH OF STATIC 9 1 <br /> WATER LEVEL (Ft.) &DATE MEASURED <br /> , z <br /> ��}}� ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING�LL�(feet) TEST LENGTH (Hra.) TOTAL'DRAW13OWN (Ft.) <br /> TOTAL DEPTII OF CONIPLETED WELL as , .. (Feet) *Alay not be representative of a wefd long-tens yield <br /> DEPTH CA5ING(&) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE PROM SURFACE TYPE <br /> DIA. 4MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inchee) GRADE DIAMETER OR WALL IF ANY MENT TDNITE FILL FILTER PACK <br /> Ft. to Ft. ` (Inches) THICKNESS (Inches) Ft, to Ff. (�) (TYPVSIZE) <br /> ' Ltt t 'il 4P0 ' <br /> ILA ' L 11 LI flo <br /> e , <br /> r r <br /> ATTACRMENTS (J) CERTIFICATION S.TATEAIENT <br /> Gacloglc Lop1,the undersigned,curlify that this report Is compfete and accurate to the best of my knowledge and belief. <br /> lru <br /> �. <br /> Well Gansction Diagram NAME �ri.Jl l.-/lL`�l t?1 ' <br /> Geoph (MSON, RRIA, OR CORHYMTION) (TYPED OR PRINTED) — <br /> �.. SollfW ter Lau(s) -V�g I ` 1,4 <br /> SoillVlaler Chemical Analyses v <br /> ADDRESS My STATE 21P <br /> Other <br /> ATTACH ADDITIONAL INFOAAMrIoA IF IT EXism Slgned <br /> I III WELL DRILLER AUTHORIZED REPRESENIAIN& DATE SIGN D C-57 LICENSE NUMBER <br /> V%Va186RZV,7.90 IF ADDITIONAL SPACE 15 NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM �� <br />