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QUADRUPLICATE STAFF 01• CA1IFORNIA DWR USE ONLY --DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> STATE WELL NOISTATION NO <br /> // Rcfcr to Iiislrachun Pnuldihlrt ❑ <br /> Page_o� Fjl11 !f.I NoF7 T Ll <br /> WeII No 820507 <br /> LATITUDE LONGITUDE <br /> Date Work Began Ended <br /> Local Pet telt Agency t ! <br /> �' y APNlTRSIOTHER <br /> Pei mit No Peril Date I <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION I Z__VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) N till(: Ir � f <br /> DRILLING JJ .1f �. / 'r / / �• <br /> METHOD l f r�FLUID Mailing Address <br /> DEPTH FROM (- f„ <br /> SURFACE DESCRIPTION <br /> Ft to Ft Dewribe wall Main 5i_( (olor elc CITY STATE ZIP <br /> IVELL LOCATION.. <br /> I I Address <br /> I I <br /> city <br /> I County ✓' ` r <br /> APN Book P tge Parcel <br /> f TownSlnp R-inge Scctloa] <br /> L ititllde 1 1 NORTH Longitude WEST <br /> Ir f°�� ! f DEG MIN SEC DEG MIN SEC <br /> G 7 ! LOCATION SkLTCII ACTIVITI (�) <br /> / I n(J NORTH <br /> NEW WELL <br /> MODIFICATIONlREPAIR <br /> Deepen <br /> Other(Specify) <br /> I � <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGIC LOG <br /> PLANNED USES (!) <br /> 12 <br /> I I WATER SUPPLY <br /> Domestic - Public <br /> Irrigation Industrial <br /> I I w MONITORING ' <br /> I TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> 3 s <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGING <br /> SOUTH REMEDIATION <br /> IILnPratr or Descnbc Mvtawo of 111,11{rnnr Roils Buddings <br /> I I <br /> Ft urn RlLcrs eic and attach a rnrr+> v addittowd palm If OTHER(SPECIFY) <br /> necessary Pit AS1- BL ACCURATE d:COMPLETE <br /> WATER LLVLL & IIELD OF COMPLETED N%LLL <br /> DEPTH TO FIRST WATER .t (Ft) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> I I _ ESTIMATED YIELD (GPM) & TEST TYPE - <br /> TOTAL DEPTH OI. 130RLNC (I c(t) TEST LENGTH (Hrs)TOTAL DRAWDOWN (F]) <br /> TOTAI DEPTH OF COMPLETED N�ELL /'—f (deet) *Alay not be 7epi IswlaftD6 of a we/ii/onj�rani yr(let <br /> DEPTH CASINC (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE DOLE HOLE O TYPEFROM SURFACE TYPE <br /> DIAr z Q a MATERIAL! INTERNAL GAUGE SLOT SIZE UE t1EN <br /> (Inches) z w �� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m ovo Nnches) THICKNESS (inches) Ft to Ft (�) (� } (� ) (TYPE/SIZE) <br /> a.� y d I Ifs°� / 1✓ <r'� I ''. X _ <br /> I <br /> I <br /> I <br /> ATTACHMENTS (z} CERTIFICATION STATEMENT <br /> I the undersigned certify that this report Is complete and accurate to the best at my knowledge and belief <br /> Geologic Log <br /> Xr f <br /> Well Construction Diagram NAMF <br /> {PERSON FIRM OR CORPORATION) (TYPED DR PRINTED) <br /> Geophysical Logs) <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> WELL DRILLFR/AHTHORIZEDUPRESOTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> uu R ISS BEN 11 rr- IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />