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' ORIGINAL STATE OF CALlftORNIA R s N — . o 121 <br /> File Y+ith DWR WELL COMPLETION REPORT ° ' �I ° / " <br /> 1 Refer to Inftrrre,iorr Pamphlet STATE WELL NO,ISTAT(0N NO. <br /> ' Page of ❑ <br /> Owner's Well No. No. 5""�6 C�Q <br /> Date Work Begun En{led ` I 1 O v LATITUDE LotaarnrDE <br /> Local Permit Agency <br /> ' _ r o <br /> Fmraft No. �� 121 - Permit Date <br /> GEOLOGIC LOG <br /> "%20! <br /> � WELL OWNER -�--- <br /> ORIENTATION (4)�,.VERTICAL —]HORIZONTAL ANGLE (SPEC <br /> EFY) Nartt�' <br /> DEPTH TO FIRST NATES L�s-_.(FL)BELOW SURFACE Ma iing Address <br /> DEPTH <br /> DESCRIPTION <br /> Ft, to Fi. Describe xnaterinl,gain fize,color,etc. • �� 'CITY S s STATE ZIP <br /> WELL I.00ATI N <br /> ID <br /> } 'Address'. <br /> -County _ <br /> r1PN Bookr`L Page 1°1roe1 » _ <br /> 1 <br /> Township��Range Section t r. <br /> •LittStude11 -t aroRTrs Longitude vut;sT <br /> ❑EQ MIN. SEC, DEG, MIN. SEC. <br /> LOCATION SKETCH A6TIVI'TY (2L) <br /> e r NORTH 1/ <br /> NEW SYELL <br /> r <br /> MDDIFIDATIONlREPAIR <br /> r r r <br /> _Devpen <br /> ri u }J _Other(Specify) <br /> + <br /> DESTROYCOssaa6a <br /> 7 ProcedareaendMelarlals <br /> � ' • ' Urtder"GEOLOGlCLCG') <br /> PLAD USE(S) <br /> r <br /> TURING <br /> - `cr <br /> ' ' V WATER SUPPLY <br /> �. <br /> �C � <br /> 00msslta <br /> r , <br /> _ PubNfc <br /> r — Irrigation <br /> ' ' 4 Industrial <br /> "TEST WELL" <br /> `.... <br /> CATHODIC FROTEC- <br /> 1 SOUTH TION <br /> Iifrisfrafe or Describe Durant¢ofWeil from I-as,drrwrfas �OTHER(Specify) <br /> such W rinails,fluddings,Fences,w era,etc. <br /> PLEASE BE ACCURATE L- COMPLM'. <br /> i e � <br /> ! METHOD 1 �tfi � )r FLUfD <br /> W TER LEVEL h YIEL OF CO3IIkLET DDEPTH 1 TsLI. <br /> ' r <br /> WATER:�EV IATIC 9 F ST <br /> ' (Ft.) & DATE MEASURED <br /> r r�� ESTIMATED YIELD* (GPM) d TEST TYPE <br /> ' TOTAL DEPTH OF BOHING moi—((Feet)) TEST LENGTH (Hm.) TOTAL DDRAWDOWN (Ft.) <br /> y <br /> TOTAL DEPTH OF COMPLETED WELL (Fee() w May not he Teprefewalive of a welll;fang-tam yield, <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FRBORE- <br /> oM SURFACE }.IDLE TYPE ' FROM SURFACE Typg <br /> DIA. MATERIAL! <br /> INTERNAL GAUGE: SLOT SIZE <br /> s d 'd' �E�TT(0 <br /> {Inches) s o CIRADE DIAMETER OR WALL 1F ANY M17E F)LL FILTER PACK <br /> FL to Ft, cv� U= (laches) THICKNESS (Inches) Ft. to Fl. f (TYPEISIZE) <br /> ' :a ItA 1� ` <br /> , r <br /> , r <br /> 1 r r <br /> ATTACHMENTS (f) CERTIFICATION STATEMENT <br /> Geologic Leg 1,the undersigned,certify that this report Is`complete and accurate to the bust of ITIy knowledge and belief. <br /> Well Cnnstrucko Diagrnm NAME <br /> (PERSON,FIRIA,DI CD8F0MfIDN) (TYPED DR FIRMED) <br /> ._. Geaphyslcar Lnp(s} <br /> � <br /> ,�,_• Solli lolcr Che4cal Analyzes <br /> ADDflES CITY STATE Z1P <br /> Othor <br /> ATTACH ADDMONAL fNFQRMATION.IF IT EXIST8. Signed <br /> ELL DRILLERIAUTNI)RlZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWTttaslFV.7-so IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FOAM <br /> r <br />