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ORIGINAL � <br /> STATE OF CALIFORMA D W R USE ONLY L Y D O T I L { <br /> File with DWFt - s WELL COMPLETION REPORT i� L Am <br /> 1 Page--h Of�— Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's WeH No No4 7�r��� � 0 <br /> Date Work Began 'i/ Ended 17- AL= LATITUDELDNOITUDE <br /> Loc'.al Permit Agency zk " <br /> Permit Na Permit - e tl y APNITASJOTH1511 <br /> GEOLOGIC LOG _ WELL OWNER <br /> ORIENTATION (!) VERTICAL —HORIZONTAL _ANGLE —(SPECIFY) Name <br /> DEPTH FROM DEPTH TO FIRST WATER (Ft) BELOW SURFACE { "�Vlalling Address eta E oaf _ 1�7.,o.�"E�� <br /> SURFACE DESCRIPTION ` , ,s 4 w t �� <br /> Ft to Ft besenbe ritarerral grmn size color,dO <br /> o s` �+("CITY a " ? " <br /> WELL CAT N s ATE ZIP <br /> iE ~ ` t <br /> y APN Book (�i_!��1'age Parcel <br /> " '� y t j Toctfnsi p.2 Q Range Section L�titude� NORTH Iongatude wEsr <br /> \ " DEG MIN SEC DEG N SEC <br /> LOCATION SICETCHIVITY (!} <br /> ` - ° `' 'rig NORTH if NEW WELL <br /> ael <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> r <br /> DESTROY fD and <br /> Mao <br /> Procedures and Mafarlefe <br /> UnderEOLOGICLOG) <br /> PLA ED USES) <br /> W C ✓} <br /> MONITORING <br /> + WATER SUPPLY <br /> r <br /> 1 � <br /> ,.. Domesllc <br /> 1 i Public <br /> I <br /> Irrigation <br /> + I <br /> Industrial <br /> + I .....` TEST WELL <br /> + CATHODIC PROTEC <br /> SOUTH Illustrate or Descrfbe Distance of Well from Landmarks _ ON <br /> OTHER(Specify) <br /> Roadssuch as Rivers etc <br /> + I PLEASE BE ACCURATE&eCOMPLETE <br /> 1 DRILLING <br /> METHOD FLUID X/14 <br /> ATER LEVEL�dt IELD OF COMPLETED WELL <br /> 1 I DEPTH OF STATIC <br /> WATER LEVEL (Ft) & DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING _(Feet) TEST LENGTH (Hra) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPLH OF COMPLETED WELL(Feet) 'May not be representative of a well's long-term yaeld <br /> DEPTH CASING(S? DANNULAR MATERIAL <br /> FROM SURFACE BORE_ CASING SDEPTH*Z� <br /> HOLE TYPE FROM SURFACE <br /> CIA MATERIAL/ INTERNAL GAUGE SLOT SIZE TYPE <br /> (Inches) `" GRADE DIAMETER OR WALL IF ANY CE BER FILTER PACK <br /> Ft to Ft $S (Inches) THICKNESS (Inches) Ft to Ft MENT TONFfE FILL (TYPE/SIZE) <br /> (4) f,, ) (zl <br /> !20 ' z— 1-5c-4 q61 .0 2+a 1 -F <br /> 1 <br /> 1 <br /> r � 1 <br /> , I <br /> 1 <br /> TACHMENTS (✓) CERTIFICATION STATEMENT <br />' f <br /> eologic Log I,the undersigned Certify that this report Is complete and <br /> -accurate to the best of my knowledge and belief <br /> ell Construction Diagram NAME v/(, <br /> eophystcsl Log(a) Q� <br /> (PERSON f URPURAT (TYPED OR PRINTED) <br /> od/Water Chemical AnalysesADDRESS CITY STA Ether f <br /> IONAL INFORMAnON 1F IT EXISTS Srgned I rj 4�, <br /> WELL DRILLER/Afi}THO p PRESENTATI DATE IGNEg C 57 UC£NSE NUMBER <br /> DWR189REV 7-90 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br /> r1 r <br /> n <br />