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r <br /> ORIGINAL STA re t)h ( X1.11 t)11NIA W Rv — <br /> File with DWR WELL COMPLETION REPORT <br /> Page l of__L Refer to Inrtruttion Pampbler STATE WELLNO/STATION NO <br /> Owners Weil No No 474181 <br /> ��� i <br /> Date Work Begin rZ Ended LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No Permit a e l . <br /> GEOLOGIC LOC <br /> WELL OWNER <br /> ORIENTATION (!} VERTICAL __, HORIZONTAL ANGLE —(SPECIFY) Name <br /> DEPTH FROM DEPTH TO FIRST WATER (Ft) BELOW SURFACE Mailing Addresscar its <br /> SURFACE DESCRIPTION <br /> Ft ry <br /> to Ft Describe matertal Qralrt rize color etc CI WELL LOCATION SSA zIP <br /> Address 2 <br /> City <br /> County <br /> APN Book Page Parcel <br /> Or <br /> To unship 2 N Range 105a_Section 410 ,- <br /> Latitude Noon+ Longitude_ _ I - WEST <br /> DEG MIN SEC DEG IN SEC <br /> LOCATION SKETCIITIVITY {�}-- <br /> ' NORTH ZNEW WELL <br /> i MODIFICATION/REPAIR <br /> Deepen <br /> i <br /> [J Other(Specify) <br /> Q M ! <br /> .y DESTAOY(Descnbe <br /> ' ' \ Procedures and Ailatenals, <br /> Urtder GEOLOGICLOG)I <br /> I U)- ` y PLAc EID U5E(S) <br /> LU <br /> lL (� <br /> MONITORING <br /> WATER SUPPLY <br /> — Domestic <br /> ( /�J Public I <br /> i i IIIJJJ Imgauon <br /> Indeatrtal ' <br /> I <br /> TEST WELL <br /> CATHODIC PROTEC <br /> SOUTH TION <br /> Illustrate or Desertbe Distance of Well from Landmarks ._ OTHER(Specify) <br /> such as Roads Buildings Fences Rivers etc <br /> PLEASE BE ACCURATE & COMPLETE <br /> DRILLING 1{ 1A _2 <br /> METHOD�`-�-OU.bt_.] 'F�t� _,_FLUID <br /> WATER LEVEL & YIELD OF COMPLETES WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) R DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING _ _(Feet) TEST LENGTH Mrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL �i�, (Feet) 'May not be representcttve of a wells long-term yuld <br /> DEPTH CASING(S) ANNULAR MATERIALBORE DEPTH <br /> FROM SURFACE HOLE TYPE —' FROM SURFACE TYPE <br /> DIA <br /> INTERNAL GAUGE SLOT SIZE <br /> x tt:W aQ a MATERIAL/ DIAMETER OR WALL IF ANY CE BEN <br /> Ft to Ft <br /> (Inches) Q on GRADE MENT TONITE FILL FILTER PACK <br /> aj N ca (inches) THICKNESS (Inches) Ft to Ft ✓ (TYPEISIZE) <br /> Pv'c._ 2 § 65� <br /> Z- q6 .oases <br /> t <br /> Z <br /> "TTACHMENTS (!) CERTIFICATION STATEMENT <br /> Geologic Log I,the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Weil Construction Diagram NAME l�f r0�1 _ --C;7 flit) �4f 1 . Lr-rg <br /> (FERcnp ci OAPORA (TYPED OA PRINTED) <br /> bd <br /> Geophysical Log(s) <br /> Soil 7Water Chemical Analyses C, r <br /> ADDRESS <br /> Other CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed7- <br /> WELLDRILLER/ PRESENTATI DATE IGNED C 57 LICENSE NUMBER <br /> DWR IRR REV 7 90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />