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' ORIGINAL. STATE Or CALEFOR,vu no Nor FlI.LjN_ <br /> — <br /> F€le with DWR WELL COMPLETION REPORT 0 ( w ° 6 /1 v <br /> Page of 1— Refer ra lntrrncsronPorngblu STATE WELL NO.19TATtON N0. <br /> ' C ner's Well No. W �" N9' 576677 <br /> Date Work Began Ended n LATITUDE toNG)Tuos <br /> Lacs]Permit Agency v% D1U. <br /> Permit No. Permit Date .� &D DVA, R N sr <br /> ' GEOLOGIC LOG <br /> ORIENTATION (L) VERTICAL HORIZONTAL ANGLE •(SPECIFY) Name": -kb"V <br /> DEPTH FROM DEF.''H To FIIIST WATER9_+15_(Tt.)BELOW SURFACE r . 'Mails' ddre4 <br /> SURFACE I1Ts5CRIPTION <br /> ' STATE ZIP <br /> Ft. to Ft. Aer 'bei at '!groins°re,mtor etc •, ` ' L ' t }irELL, LQCATIO <br /> 1 r r � i'�(lflIeSS{ �1 <br /> City. <br /> ,caL(TtCy svx1�. <br /> 11PN Book Page Pttrce]C`] <br /> T,)Iynshtg . flange section <br /> r A LatltttCle NORTH Langihtde— 1. t WEST <br /> i , + DEG. MIN. SEC. DEG. MIN, 5E0. <br /> r f': —LOCATION SKETCH ACTIVITY (2!L11 <br /> NEW WELL <br /> MOOWICATIONISEPAIR <br /> �� Deepen <br /> _._.Olher(Spes(ty) <br /> ' I ,..,.DESTROY(Vescr)ke <br /> i <br /> '•s '.• '•t ; PwcedureaandMalertals <br /> Under"GEDEGGlCLOO'? <br /> � � PLAi�iNEA USE(S)- <br /> Mo <br /> t `. u � M6N 70Ri3+14 <br /> � r <br /> i WATER SUPPLY <br /> r L. <br /> _._. Dornellic <br /> r Nblle <br /> talpallon <br /> r <br /> Industrial <br /> "TEST WELL" <br /> �.CATHODIC PROTEC• <br /> SOUTH tION <br /> 7HnSlrnre or))escrl(ta Dfslnnce of Well front Landmarks OTHER(Specify) <br /> such as Roads,)3uf1d(ngs,Fences,Rfoers,ale. <br /> PLEASE I)E ACCURATE 'v COJUPLETE. <br /> DRILLING <br /> , METHOD l L�JL 3�' 4f+'� FLUID <br /> WATER LEVEL h YIELD OF COMPLET�D Y EGL <br /> DEPTH OF STAIR rr <br /> WATER LEVEL_ -, (FL)& DATE MEASURED <br /> r I <br /> ESTIMATED YIELD' (GPM) d TEST TYPE <br /> TOTAL DEPTEI OF BORING e{ eat TEST LENGTH (Hre.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETFI)WELL + (Feet) #Alay not be repretentative of a well r brig-teen yield. <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> HOLE W—,' FROM SURFACE TYPE <br /> INTERNAL GAUGE SLOT SIZE <br /> Ft. to FL (In°1t6a) II MOTRADs ALL IF AL! DIAMETER OR WNY CEBEN- FILTER PACK <br /> (fiches) THICKNESS (Inches) FL to Ft. MENT TQNIT£ FILL (TYPE/SIZE) <br /> L r L <br /> t <br /> r ' <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> Geologic Lep f,the unde(signed,ce�rtifly that ih(s repot(is complete and accurate to the best of my knowledge and belief. <br /> Well Con9Uuclfon Diagram NAME VvCl.A Geophypical Log(s) ` � r <br /> (PERSON, FIRMOR CORPGRAATION) (TYPED OR PRIIiTED <br /> ..� 5aflJWater Chelnlca!Analyses `ma =y $ 4-1-CITY i1\S1AiE 2M' <br /> ADDRESS -- <br /> _ 5-11 <br /> � ��k , '11015 <br /> ATTACH ADD1770M70NAL INFORMATION.IF)T EX15TS. Signed V <br /> -14 <br /> W)LL�VIILLjER�1�111111ZEISENTATIVE DATE SIGN£ G57 LICENSE UMARER <br /> D%VRISS R6V.7-g0 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM 1 <br />