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QUADRUPLICATE STATE OF CALI ORNIA D W R USE ONLY — DO NOT FILL I <br /> J For Local Requirements <br /> WELL COMPLETION REPORT <br /> Page---t of_ Refer to Instruction PQyriphlei STATE WELL NO[STATION NO <br /> Owner's Well No 17J-•2 NoFF7 <br /> A ��+►�,"j l V 6 <br /> 2 <br /> Date Work Began __ 24193 Ended V76/93 "� �+ LATITUDE LONGITUDE <br /> Local Permit Agency San !tagt3 n gm !L FiUbUC 1.1 12at7 r'aM � <br /> Permit No 93=29 Permit Date 72A192 R ' <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) i� VERTICAL _ HORIZONTAL _ANGLE — (SPECIFY) Name UTt'-rd <br /> DEPFROM DEPTH TO FIR`iT WATER (Ft) RFI OW SIJRFA(F Mailing Address39241 �Pnt �-=1Q� <br /> TH <br /> SURFACE DESCRIPTION — CA <br /> Ft to FtDescrrbe rtratenal grain srze,color,etc CITY STATE ZIP <br /> I , <br /> WELL LOCATION <br /> Address C <br /> Citystockt= <br /> p' County " + C germs <br /> in <br /> I I � <br /> APN Book Page Parcel <br /> TownshipRanp�e Section <br /> Latitude i- i 00 U" Noah+ Longitude 121, 19 , G WEST <br /> ' DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCHR, ACTIVITY (4 <br /> X <br /> NORTH <br /> _ NEW WELL I <br /> i , I <br /> MODIFICATION'REPAIR <br /> —Deepen <br /> _Other(Speedy) <br /> I I <br /> I <br /> _DESTROY(Describe <br /> Procedures and Mafensts <br /> Under GEOLOGIC LOG) <br /> PLANNED USES) <br /> i W MONITORING <br /> I , <br /> ' WATER SUPPLY <br /> I I <br /> Domestic <br /> , <br /> Public <br /> Irrigation <br /> I <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 Riners eic <br /> PLEASE BE ACCURATE dr COMPLETE <br /> I I <br /> DRILLING "tinta= j.6ght: FM <br /> METHOD FLUID <br /> WATER LEVEL & YIELD OF COMPLETFD WELL <br /> DEPTH OF STA� r��t <br /> WATER LEVEL ii (Ft) & DATE MEASURED--315/93 <br /> I I <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feg c 1 EST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL aJ (Feet) May not be representative of a well's long-term yield <br /> DEPTH CASINC(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE ✓ FROM SURFACE TYPE <br /> HOLE — INTERNAL GAUGE SLOT SIZE <br /> DIA ,G a MATERIAL! CE BEN <br /> z w a� DIAMETER OR WALL IF ANY FILTER PACK <br /> (Inches) a m 8 ccs GRADE MENT TONITEJ FILL <br /> Ft to Ft c» (Inches) THICKNESS (Inches) Ft to Ft (TYPEISIZE) <br /> i n i t <br /> -vs.r v rr�Pcflsl <br /> IL <br /> I <br /> I I <br /> I <br /> 1 <br /> ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> 1 I the undersigned pcertify.that this report is Complete and accurate to the best of my knowledge and belief <br /> Geologic Log J�1 ym—z-4 .1st=n Co—:=my <br /> Well Construction Diagram NAME <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) ��� r��" �a� 9& y`��� d � 9559-9Soil!WP( r Cherry Analyses a _ <br /> rs ��'� y�atl ADDRESS / CITY STATE ZIP q <br /> ' Other <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> WELL DRILLER AUTHORIZED REPRESENTATIVE DATE SIGNED C57 LICENSE NUMBER <br /> DWn 1SSRLV 799 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />