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ORIGINALSTATE OF CALIFORNIA DWR USEONLY — D N O i F I <br /> File with DWR `YELL COMPLETION REPORT <br /> Page—A—of_ <br /> I Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> 447436 0❑ �❑ <br /> Owner's Well No. sir�IA/^' 3 No. <br /> Date Work Began tO � Ended Na 4 LATITUDE LONGITUDE <br /> Local Permit Agency MV . drAl—T-14 <br /> Permit No. Permit Date 9L APN/ / <br /> OTEJER <br /> GEOLOGIC LOG ./��1,rr^ -WELL OWNER <br /> ORIENTATION (!) —VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name r/'�` Ce"D.0.iN?-7Ot1 <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE Mailing Address 12_3!T_ <br /> /�fil-2KET ST,Z,EFT <br /> DEPTH FROM <br /> �u-�L�.b�L���. <br /> SURFACE DESCRIPTION —t <br /> Ft. to Ft. Describe material,gram nia,color,etc. CITY STATE 21P <br /> WELL LOCATION <br /> Address .2`95 5, t477 h W6:y a9 <br /> City <br /> drva Count, �j ]IQ„Lll <br /> 12- IA4:dtAa 1v Jew Aptitn( 0. APN Book Page Parcel <br /> Ali 1424-- C&L Township Range Section <br /> or <br /> l i1 .Latitude DEGMIN. SEC. DEG.NORTH Longitude MIN. SEC. WEST <br /> . <br /> h �'FoM LOCATION SKETCH ACTIVITY (�) <br /> / lr OL+[.e1'1� NORTH _NEW WELL <br /> �f <br /> '1 ��-t"D ✓L �C�1. - MODIFICATION/REPAIR <br /> C&< n A CIE: L�� _Deepen <br /> 1 L - . / —Other(specity) <br /> L, _..J O`lS t Coll 11A} DESTROY(Describe <br /> 4 11511-insr.L�l l Pre <br /> recedueandMithriats <br /> l Under"GEOLOGICLOG") <br /> PLANNED USE(S) <br /> 3 m MONITORING <br /> WATER SUPPLY <br /> Domestic <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 Roods,Buildings,Fences,Rivers,etc. <br /> PLEASE BE ACCURATE & COMPLETE. <br /> r <br /> DRILLING <br /> METHOD FLUID <br /> 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 (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) a May not be representative of a well's long-term yield. <br /> CASING(S) EPTH ANNULAR MATERIAL <br /> H BORE- FRO URFACE TYPE <br /> FROM SU HOLE TYPE <br /> = MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN. <br /> (Inches i W - GRADE DIAMETER OR WALL IF ANY MENT TONRE FILL FILTER PACK <br /> Ft. to Ft. _ (Inches) THICKNESS (Inches) (TYPE/SIZE) <br /> ATTACHMENTS (2) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> t <br /> _ Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR IN REV.7-9D IF ADDITIONAL SPACE 15 NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />