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0AIGINAL STA('E olH ( %L.II OIINIA USE ONLY DO N T Fl 1 N <br /> File with DWR WELL COMPLETION REPORT <br /> Page_J_of Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner s Well No �� .. No 474180 IT11Date Work Began 2 3 — Ended 3 LATITUDE LONG1ruDE ❑ <br /> Local Permit Agencv $ 3' <br /> Permit No Per ateAP ITRSIOTHzR <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (!L VERTICAL — HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DDEPTH TO FIRST WATER �(Ft) BELOW SURFACE Mailing Address L., � <br /> EPTH FROM <br /> SURFACE DESCRIPTION -� <br /> Ft to Ft Dercnbe material grain seze color ere GTY STnrE ZIP <br /> WELL LOCATION <br /> Address 53a W ad <br /> City <br /> County <br /> APN Book Page Parcel <br /> Township K) Range _Section gs <br /> or <br /> Latitude I NOR7H Longitude _ WEST <br /> i DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH 1CTIVITY <br /> N RTH NEw WELL <br /> MODIFICATION/REPAIR � <br /> Deepen <br /> i , I <br /> —Other(Specify) <br /> .{` <br /> DESTROY{D <br /> Procedures andnd Mat Materrafs� <br /> Under GEOLOGICLOG) <br /> m <br /> PLED USE(S)- <br /> ' w (f) <br /> ' MONITORING <br /> WATER SUPPLY <br /> i _ Domestic <br /> 4 <br /> Public <br /> r <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 r t _�n(! <br /> METHOD `^ L.-) FLUID <br /> FLUID <br /> WATER LEVEL h YIELD OF COMPLETE WELL <br /> DEPTH OF STATIC I <br /> WATER LEVEL (Ft) E DATE MEASURED <br /> ESTIMATED YIELD' (GPM) di 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 t long-term yield <br /> DEPTH CASINGS) ANNULAR MATERIAL <br /> FROM SURFACE BORE V DEPTH <br /> HOLE TAPE FROM SURFACE TYPE <br /> DIA ,t z i <br /> MATERIAL/ <br /> INTERNAL GAUGE SLOT SIZE <br /> r� x o a DIAMETER OR WALL IF ANY CE BEN <br /> Ft to F( (Inches) H 1 GRADE Qnches) THICKNESS HENT 70NITE FILL FILTER PACK <br /> m _ {Inches) Ft t0 Ft (4 ) (4 ) (4) (TYPE/SIZE) <br /> AO <br /> 3 <br /> AACH,MENTS (!) CERTIFICATION STt►T£MENT <br /> Geologic Loa I the undersigned certify that this report is complete and/accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME Vlyd^j <br /> (PERSON M OR DRPUAA (TYPED pR PRINTF{)) <br /> Geophysical Log(3) <br /> Soil!Water Chemical Analysea <br /> ADDRESS <br /> Other iTY STAT ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS SignedZ Z 3 5-11-2 <br /> WELL DRILLER? DRIZED EPRES A DATE SIGNED _G_57 LICENSE NUMBER <br /> DWR ISh REQ -go IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />