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ORIGINAL <br />File with DWR <br />Page —L Of <br />Owner's Well No <br />Date N%ork Begin _ <br />Local Permit Ag <br />• Permit No _ <br />ORIENTATION (� ) <br />DEPTH <br />SURF, <br />FL 1,0 <br />t --r <br />STATE OF CkLIFOR\1A <br />WELL COMPLETION REPORT <br />Refer to Instruction Pamphlet <br />No 9633 <br />12 20 41 , Ended v212004-1-1, <br />STATE WELL NO !,STATION NO <br />D ID F] <br />LATITUDE LONGITUDE <br />APN/TRSJOTHER <br />Permit Date <br />4 3 It C2 <br />CASING (S) <br />GEOLOGIC LOG <br />DEPTH ANNULAR MATERIAL <br />FROM SURFACE <br />IIELL OWNER <br />FROM SURFACE TYPE <br />TYPE (2: ? <br />�� <br />VERTICAL _ HORIZONTAL _ ANGLE _ <br />(SPECIFY) <br />Nome <br />z cc a <br />°J <br />�� a <br />MATE6RiAL 1 INTERNAL GAUGE <br />GRADE DIAMETER OR WALL <br />DRILLING �7 <br />;vlailing Address <br />OIc <br />Ft to Ft <br />METHOD _ FLUID <br />¢ <br />m 1 <br />(inches) THICKNESS <br />{Inches) <br />CA C 83 <br />DESCRIPTIO <br />o w <br />Describe matertal, grain size color etc <br />Cin <br />STATE Zip <br />2—e1 <br />E OCATIO\ <br />I uv. SI <br />Addiess 30, <br />w <br />r St <br />city L41104 I <br />01020 <br />I 6 S X <br />County1001vlon <br />I St c <br />AP\ Book. <br />Page <br />Parcel <br />Io,.%mship Rance Section <br />tSkxpY Latitude NORTH Longitude I I "ES- <br />Lr DEG MIN SEC DEG MIN SEC <br />ti3 i LOCATION SKETCH iCTINITS (,.) — <br />NORTH NEW WELL <br />q i 46 I _ — -.. _ MODIFICATiON1REPAIR <br />—VZr !�a I �[ �� !'� Deepen <br />i T Other (Specify) <br />r <br />I r <br />r I <br />y i I / <br />•r/ +C+i <br />L. /6 t Cx W L L nx <br />i 6 t i <br />D r '70.- <br />-A-) <br />0- I Sr C <br />—7S r <br />7 i7 r u <br />Ci_S <br />t + <br />r <br />r <br />I I <br />r i <br />r , <br />r <br />I i <br />i I <br />t � <br />TOTAL DEPTH OF BORING (Feet) <br />r <br />TOTAL DEPTH OF COMPLETED 5fi ELL i <br />Feet) <br />W- ke- Wka v% <br />DESTROY {Describe <br />Procedures and Material, <br />Under GEOLOGIC LOG <br />PLANNED USES (2�. ) <br />WATER SUPPLY <br />Oomesac Pubs', <br />IrngauOn —�� IndLs r a <br />r <br />14 MONITORING <br />TEST WELL _ <br />CATHODIC PROTECTION _ <br />HEAT EXCHANGE _ <br />DIRECT PUSH _ <br />INJECTION _ <br />VAPOR EXTRACTION <br />SPARGING <br />SOUTH REMEDIATION <br />Illustrate or Descrrbi Dntance of It el! from Roads Buddinar <br />Fences R, Leg etc and attach a mapp Uic additional aper If OTHER {SPECIFY} <br />necessanj PLEASE BE ACCT PLATE L- COUPLETS <br />II ATER LEI EELS�&[[YIELD OF COMPLETED I1 ELL <br />DEPTH TO FIRST WATER �'_+ (Ft) BELOW SURFACE <br />DEPTH OF STATICJ,' f -.312-/U <br />WATER LEVEL L �` (Ft) & DATE MEASURED . <br />ESTIMATED YIELD (GPM) & TEST TYPE , <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (R) <br />' May not be representarize of,7 4ell r long-tenir yield <br />DEPTH <br />D%%R [IS REI it e7 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />CASING (S) <br />DEPTH ANNULAR MATERIAL <br />FROM SURFACE <br />BORE <br />HOLE <br />FROM SURFACE TYPE <br />TYPE (2: ? <br />DIA <br />Inches <br />{ I <br />z cc a <br />°J <br />�� a <br />MATE6RiAL 1 INTERNAL GAUGE <br />GRADE DIAMETER OR WALL <br />SLOT SIZE <br />IF ANY <br />CE BEN <br />MEN{ TONITE FELL FILTER PACK <br />Ft to Ft <br />¢ <br />m 1 <br />(inches) THICKNESS <br />{Inches) <br />Ft to Ft (TYPEJS1ZE) <br />(✓) (✓) (! } <br />o w <br />2—e1 <br />i 63 <br />Lt0 <br />01020 <br />I 6 S X <br />b r -76 <br />r <br />I <br />' <br />r <br />11TTACHME\TS <br />' <br />CERTIFICATION STATEbIENT <br />1, the Undersigned, certify that thrl is Is complete and accurate t0 the best of my knowledge and belle[ <br />w Geologic Log <br />tV} � 1114 <br />{ <br />Well CCnstruCtson Diagram <br />NAME (PERSON FIRM OR CORPORATION (TYPED 0� TE01 <br />— Geophysical Logs) <br />C Q q} 5 —7 1 <br />' f <br />— SolyWater Chemical Analyses <br />ne,1 <br />ST <br />STAiEy�DZI�o`'ATTACH <br />" Other <br />:ADDRESS <br />3 j5 <br />ADDlTlQNAL fNFOAMATlON !F !T EXISTS <br />g"�=RiAuTHORIZED ATIYE <br />DATE SIGNEp C 57 EICENSE NUMBER <br />D%%R [IS REI it e7 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />