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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Refer to Instruction Pamphlet <br /> Page of � STATE WELL NO!STATION NO <br /> El11Owner's Well No }�_+I -1(r No 464958 <br /> Date Work Began w �'��on 1l^ i � 'W&O«-1/�7 LATITUDE LONGITUDE <br /> Ended <br /> Local Permit Agency Olt ,`,r r r r r t ( <br /> Permit No t) 1 r 1` f Permit Date /1 Jr (l — APN/TR / H <br /> GEOLOGIC LOG c / "jELL OWNER <br /> ORIENTATION (�J VERTICAL — HORIZONTAL — ANGLE —(SPECIFY) Name_"She! )J / <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE , Mailing Address _#� �� tax,y i tJ aI <br /> DEPTHDEPTH <br /> DESCRIPTION l f K II <br /> r <br /> Ft to Ft Describe material,gram CITY sate,color,etc � ` * `; WELL LOCATION STATE ZIP <br /> 4 <br /> Address t elf 1 I l/ttl�A 1 dIl g 1, <br /> — <br /> f Citv <br /> T1 trM (' County fIv t _Tt `lrl {Ili, ) <br /> r a r APN Book Page Parcel <br /> a { J T or <br /> Township Range Section <br /> )) f s i i or <br /> Latitude I NORTH Longitude I WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (!) <br /> NORTH — NEW WELL <br /> MODIFICATION IREPAIR <br /> ' i v '•-� 7 —Deepen <br /> '! _Other(Specity) <br /> i <br /> DESTROY(Describe <br /> Procedures and Materiels <br /> Under GEOLOGICLOG) <br /> .0 L' PLANNED USES) <br /> w MONITORING <br /> WATER SUPPLY <br /> i i { <br /> Domestic <br /> i <br /> 1~ <br /> Public <br /> Irrigation <br /> Industrial <br /> _ 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 <br /> I METHOD FLUID <br /> I{ WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE INTERNAL GAUGE SLOT SIZE <br /> DIA ,c w ei MATERIAL/ CE BEN <br /> (Inches) u+ o� J GRADE DIAMETER OR WALL IF ANY MENT TONETE FILL FILTER PACK <br /> Ft 10 Ft c» (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> 1 ' <br /> , <br /> , <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log <br /> the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME fw( <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 5 I f <br /> Soil/Water Chemical Analyses —_4 U-_ ' 1:, u� '',� r) I` J(�l)t f f P <br /> ADDRESS CITY STATE Ir ZIP / <br /> Other j <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed ' S # � 't� rf d <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE ; DATETE SIGNED U C57 LICENSE NUMBER i <br /> DWR 188 REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED"FORM <br />