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' ORIGINAL ! <br /> STATE OF CALIFORNIA _DWR E_ � Y �o�NOT E L I N� II <br /> File with DWR WELL COMPLETION REPORT fD E�=� <br /> Page__L of I t Refer to Instruction Pamphlet STATE WELL No!STATION NO <br /> t Owner's WeII No 1 __...,_ No474180 <br /> � q �} <br /> Date Work Began LA �`�- 3 �i `� 1 Ended ? LATITUDE ❑ LONGITUDE <br /> Local Permit Agency 59LM S <br /> "40 <br /> �, _ PN/TRS OTHER <br /> Perxntt No Permit ate <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION {.::!} VERnCAL —HORIZONTAL _ANGLE —(SPECIFY) Name, L'C—, �7 <br /> DEPTH FROM 1)EPTT-I TO FIRST WATER,ZL(Ft) BELOW SURFACE (:Maihng`Address <br /> SURFACE DESCRIPTION �,`.� ` ' <br /> Ft tin Ft Describe material,gratrl nze enloT,etc. Cn'Y STATE ZIP <br /> ;, . WELL,IiOCA'TION <br /> Address'_�, <br /> 1 a �y <br /> f- <br /> 1City <br /> �+lountay '� �^ ' .�^/ /�1� <br /> j `' � "-"- APN�Book `Pape Parcel��++--e - <br /> To onslii Range Section <br /> H ; LAtxtude— t 1 NORTH Longitude i wEsr <br /> DEG MIN SEC DEG IN SEC <br /> LOCATION SKETCH ¢'CTIVITY {r) <br /> n=.� z y NRTH <br /> NEW WELL <br /> 1` �. MODIFICATION/REPAIR <br /> IA <br /> —Deepen <br /> i <br /> f _Other(Specify) <br /> =1 DESTROY(Describe <br /> Procedurea andMetedafa <br /> Under GEOLOGIC LOG) <br /> " ' _ti V t y PLAN ED USE(S)- <br /> LU <br /> SE(S)w ¢ { L} <br /> MONITORING <br /> r WATER SUPPLY <br /> Domestic <br /> 1 1 <br /> i <br /> Public <br /> irrigation <br /> ,.,._ Industrial <br /> 1 I <br /> TEST WELL <br /> 1 i <br /> ' 1 SOUTH — TION ODIC PROTEC <br /> ' Illustrate or Desmbe Instance of Well from I artdmarhs — OTHER(Specify) <br /> ta <br /> PLEASE BE ACCURsuch as Roads ATE& COMPLETE <br /> DATELINE4�f <br /> METHOD FLUID <br /> i WATER LEVEL & YIELD OF COMPLETEb WELL <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> 1 <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEP'T'H OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be repreremauve of a well!r long-term yield <br /> DEPTH CASINGS) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ! FROM SURFACE TYPE <br /> DIA z c d MATER(ALI INTERNAL GAUGE SLOT SIZE CIE SEN <br /> (inches) DIAMETER OR WALL IF ANY MENT 7BEN FILL <br /> o� a GRADE FILTER PACK <br /> Ft to Ft m v op = (Inches) THICKNESS (inches) F1 )o Ft (TYPE/SIZE) <br /> 10 v<_ C) , <br /> 't g L Z csG.4 4D 6,0 20 �' ' 0 <br /> ' 1 <br /> iA ACHMENTS (✓) CERTIFICATION STATEMENT <br /> Glogic Log I,the undersigned Certify that this report Is complete and accurate to the best of my knowledge and belief <br /> eo <br /> - Well Construction Diagram NAME <br /> sz Geophyical Lo0(0 �(PERSON-+IK'-M^"02103 r��l�N,�e'Urg'r(To�YP'^ED cldO."R�LPRINTED) <br /> Soil/Water Chemical Analyses 2:__� <br /> Ether ADDR ,�l TThY,te (lC��I_. <br /> Gr <br /> A'TE, <br /> ZIP <br /> [� <br /> ATTACH ADDITIONAL INFORMATION IF!7 EXISTS Srgned WELL DRILLER,A DRIZED EPRE lyt1 ft;-. _ / <br /> DA <br /> 1-2-12Q <br /> IQNED C37 LICENSE NUMBER <br /> DWR188REV 791) IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />