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ORIGINAL <br />File with DWR <br />Page ! of -I— <br />Owner's Weil No <br />Daate %%ori. Began_ <br />Local Permit Ag <br />Sk Permit No <br />ORIENTATION (4 ) <br />STATE OF CALLIFOR\IA DWR SE ONLY — DO NOT FILL IN <br />WELL COMPLETION REPORT <br />Refer to Invtrr[ctton Pamphlet STATE WELL NOISTATION NO <br />NO ?29634 <br />2 f Ended l5 LATITUDE LONGITUDE <br />, VII, f0a9 fit <br />n 2 �3 q e) APNITRSIOTHER <br />r L6 - Permit Date <br />GEOLOGIC LOC WELL OWN R <br />+Z VERTICAL ____, HORIZONTAL _.... ANGLE �_ (SPECIFY) Name <br />DRILLING FLUID 'N a ing Addr ss <br />METHOD <br />DESCRIPTIO\ <br />DeSCre 1JC netitLrtal rain Size color etc Cl STATE ZIP <br />Ft. to Ft NVELLEIICICATION I <br />i <br />I l <br />[ t <br />I I <br />[ t <br />t i <br />I i <br />t , <br />t E <br />1 <br />t I <br />r , <br />i I <br />I <br />I [ <br />[ I <br />E , <br />I <br />I [ <br />I 1 <br />E 1 <br />t , <br />[ I <br />t [ <br />I I <br />t 1 <br />TOTAL DEPTH OF IBORI\Gb {Feet) <br />TOTAL DEPTH OF COMPLETED NVELL (Feet) <br />DEPTH BORE <br />FROM SURFACE HOLEff <br />DIA(Inches) <br />Ft to Ft <br />Address <br />City — <br />County <br />zea^ 30A.9 vi V% <br />APN Book. <br />Page <br />Parcel <br />Township <br />Range <br />Section <br />Latitude <br />t I NORTH <br />Longitude <br />_ I I WEST <br />DEG <br />MIN SEC <br />DEG MIN SEC <br />LOCATION SKETCH <br />ACTIVITI (zL ) <br />NORTH <br />-k NEW WELL <br />MOOIFICATIONIREPAIR <br />_ Deepen <br />..,..^0 -her (Spe0j) <br />V), Ke'Werncw% <br />W <br />�.. DESTROY (Desonbe <br />Procedures and Marerralc <br />Under GEOLOGIC LOG <br />PLANNED USES (z� ) <br />WATER SUPPLY <br />Opmaltic Publ-C <br />IragahCn Indus <br />/101 <br />MONITORING IL�� <br />TEST WELL <br />CATHODIC PROTECTION _ <br />HEAT EXCHANGE _ <br />DIRECT PUSH <br />INJECTION <br />VAPOR EXTRACTION <br />SPARGING — <br />SOUTH REMEDIATION <br />Illastrate or Desenbe Distance of hell front &i ads Butldtnge OTHER (SPECIFY) <br />Fencer RiLen etc and attach a map f se addltwiral japer of <br />necesranf PLEASE BE ACC LFA]E & CO11PLEIT <br />IVATER LEVEL & IIELD OF COMPLETED WELL <br />DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br />DEPTH OF STATIC C Ll <br />WATER LEVEL ` (Ft) & DATE MEASURED <br />ESTIMATED YIELD (GPM) & TEST TYPE <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br />" Alay not be reDresenrati, e of a 7- ell's lonit-term yield <br />CASING (S) <br />a MATERIAL! INTERNAL GAUGE SLOT SIZE <br />d GRADE DIAMETER OR WALL IF ANY <br />LL (Inches) THICKNESS (inches) <br />S 165` <br />1 <br />ATTACHVIE,NTS (� ) <br />Geologic Log <br />Well Construction Diagram <br />Geophysical Lag(s) <br />SOIVWater Chemical Analyses <br />Other <br />ATTACH ADDITIONAL INFORMATION IF17. EXISTS <br />I the undersigned certify that this <br />NAME <br />ADDRESS <br />Signed <br />DEPTH 1 ANNULAR MATERIAL <br />FROM SURFACE I TYPE <br />CE i BEN FILTER PACK <br />MENT TONiTE FILL <br />Ft to R (�) (�) t �) (TYPEISIZE) <br />i <br />E <br />CERTIFICATION STATENWNT <br />)rt Is complete and accurate to the best Of my knowledge and belief <br />D%%R 1,S REN ti y. IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />571 <br />STATE ZIP <br />�D 7Z oRl <br />