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QUADRUPLICATE STATE OF CALIFORNIA DWR S E ONLY — O N O T FILL - <br /> For <br /> IL For Local Requirements <br /> d WELL COMPLETION REPORT 1 1 1 1 1 1 ) l <br /> Page I Of E Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> g car--1 425787 ❑ n <br /> Owner's Well No `/ No <br /> Date Work Began24/93 Ended " 93 LATITUDE LONGITUDE <br /> Local Permit A ency�Sa C� y ic- L1% 9 2' 'c= <br /> Permit No Vij Permit Date AP t <br /> TRSIOTHER <br /> 11 GEOLOGIC LOGS OWNER <br /> ORIENTATION (.!!L) — VERTICAL _ HORIZONTAL _ ANGLE — (SPECIFY) Name <br /> DEPTH FROM DEPTH TO FIRST WATER + (Ft.) BELOW SURFACE M� C� BSS 39207 S. �" t � "' <br /> SURFACE DESCRIPTION .1A <br /> STATE ZIP <br /> Ft to Ft Describe material,grain size,color, etc CITY TION <br /> 3,300 4 <br /> Addre <br /> ' City I <br /> on 1C.G ( County <br /> I , <br /> APN Boot. Page Parccl <br /> or <br /> Township Rar Section <br /> or <br /> Latitude DEG MIN i SEC DEG MIN NORTH Longitude SEC WEST <br /> I <br /> LOCATION SKETCH ACTIVITY (!) <br /> NORTH NEW WELL <br /> MODIFICATION tREPAIR <br /> I —Deepen <br /> I <br /> _Other(Specify) <br /> 1 <br /> —DESTROY(Describe <br /> I Procedures and Materials <br /> 1 Under GFOLOGICLOG) <br /> I , PLANNED USE(S) <br /> w °' a (z_) <br /> W <br /> _ MONITORING I <br /> 1 WATER SUPPLY <br /> Domestic <br /> _ <br /> Public <br /> I I � <br /> Irrigation <br /> Industrial <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Descrtbe Distance of Well from Landmarks OTHER(Specify) <br /> such as Roads Buildings Fences Rtoers etc <br /> PLEASE BE ACCURATE & COMPI ETE <br /> — <br /> DRILLING <br /> I 1 METHOD FLUID <br /> WATFR LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STAT%.37 3!5/77 <br /> WATER LEVEL (Ft) & DATE: MEASURED <br /> ESTIMATED YIELD` (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (F%§ TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet)(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 — <br /> DIA MATERIAL! INTERNAL GAUGE SLOT SIZE <br /> r W o a CE BEN <br /> (Inches} z a� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft (Inches) THICKNESS (Inches) Ft to Ft (� ) (� ) (✓ ) (TYPE/SIZE) <br /> N O y <br /> da- <br /> I 1 y w <br /> id <br /> { I <br /> I <br /> I i <br /> I 1 <br /> ' 1 <br /> ATTACHMENTS (✓) CFRTTFIf ATION STATEMENT <br /> ? <br /> Geologic Log I,the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> tr,.,u3 ±f� n oa�V <br /> Well Construction Diagram NAME � <br /> Geophysical Log(s) 27(PER N FIR OR f.¢RP 10 �(TY F,p R�I T D r ry, 9V09_ <br /> Soil/Wanivo�ri�sea L C� � ] rj L.1I 7 3 <br /> ..99 ADDRESS CITY STATE q�y gZIP <br /> Other i 4-7 ,J r f 510011 <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Srgoed <br /> WELL DRILLER AUTHORIZED REPRESENTATIVE DATE SIGNED C57 LICENSE NUMBER <br /> DWR 188 tlrk 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />