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QUADRUPLICATE r, a STATE OF CALIFORNIA D W E N L Y — DO N T FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page� of Refer to Instritctran Pamphlet STATE WELL NO!STATION NO <br /> Owner's Well No rt t { `'; // No 413675 <br /> Date Work Began 1 Ended Z I/ _ LATITUDE LONGITUDE <br /> Local Permit Agency <br /> .l+ <br /> Permit No Permit Date P ! <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) X VERTICAL _HORIZONTAL _ ANGLE _ (SPECIFY) Name—Ullowd c9mgrettion <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Address 5155 <br /> DEPTH FROM <br /> SURFACE DESCRIPTIONSan R=on CA 94583 <br /> Ft t0 Ft Describe material,grain Ttze,Color,etc CITY STATE ZIP <br /> WELL LOCATION <br /> Address <br /> Sgq Attached Boring Loaq City f <br /> County <br /> f <br /> i <br /> APN Book Page _ Parcel <br /> Township T ' 1(I Range �t Section <br /> or <br /> Latitude NORTH Longitude wesr <br /> ' q Ja t DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCHCTIVITY (�J <br /> NORTH lANEW WELL <br /> i <br /> MODIFICATION IREPAIR <br /> tn� ,r� <br /> At,, —Deepen <br /> ' ti gt'�c Attachad Sito Plan _Other(Specdy) <br /> , <br /> �..DESTROY(Describe <br /> ' Procedures and Materials <br /> ' Under GEOLOGICLOG) <br /> r r PLANNED USES) <br /> w f <br /> 3 es) <br /> MONITORING <br /> ' WATER SUPPLY <br /> i <br /> Domestic <br /> Public <br /> e i <br /> Irrigation <br /> i <br /> Industrial <br /> TEST WELL <br /> _ CATHODIC PROTEG <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 /> METHOD 1i0U0 8t0M A . <br /> �QI.__FLUID No <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH OF STATIC f <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) "May not be representative of a well's long-term yield <br /> DEPTH CASING(S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE VE --' FROM SURFACE TYPE <br /> HOLEINTERNAL GAUGE SLOT SIZE <br /> DIA MATERIAL/ CE BEN <br /> (inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILLFILTER PACK <br /> Ft to Ft (Inches) THICKNESS (Inches) Ft to Ft (� ) (� ) (� ) (TYPE/SIZE) <br /> , <br /> , <br /> I <br /> ITTACHI-IFNTS (f) CERTIFICATION STATEMENT <br /> I the undersigned ertlfy that this report Is complete and accurate to the best of my knowledge and belief <br /> ' Geologic Log <br /> Well Construction Diagram NAME(PERSON FIRM OR CORPORATION) (TYPED DR PRINTF <br /> Geophysical fL��og(ys)�jj��pp$� gg ! /' <br /> Sod 1W991fdmfC'j4iTY9b19 <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> �- !♦ /f <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed � / ' r <br /> WELL DRILLER AUTHORIZED REPR ENTATIVE ` DATE SIGNED C 5l LICENSE NUMBER <br /> DWR 188 REV 7 90 IF ADDJTIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />