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ORIGINAL <br />File with DWR <br />page I of - <br />-!-Owner's Well leo <br />Date Nl orl. Began <br />Local Permit Ag <br />AM Penntt No <br />ORIENTATION (4� ) <br />Ft <br />STATE OF CjLLTFORtIA <br />WELL COMPLETION REPORT <br />Refer to Inttructtou Pamphlet <br />Ended z1z814 729636 <br />7D�`L - - Perinit Bate i j 'r::1 <br />� GEOLOGIC LOG <br />-VERTICAL, HOR3ZONTAL _ANGLE - JSPECIFY) <br />DRILLING <br />METHOD FLUID <br />DESCRIPTION <br />Describe material grain size color etc <br />I I <br />I I <br />[ I <br />I I <br />I t <br />, <br />I 1 <br />t , <br />, <br />I , <br />, <br />I I <br />I I <br />I I <br />TOT -1L DEPTH OF BORI\G 66, <br />TOT.\L DEPTH OF COMPLETED 1LELL <br />urrn — <br />STATE WELL NO/STATION NO <br />❑1 1 1❑ <br />LATITUDE LONGITUDE <br />APNITRSIOTHER <br />LL 14NER <br />Name V firt:10 <br />64 on" <br />%failing Address boa <br />L <br />CITY STATE ZIP <br />WEIJ. LOGITION , <br />Address lot <br />W <br />City LO <br />CASING (S) <br />DEPTH <br />County <br />DEPTH <br />FROM SURFACE <br />APN Boot. <br />Page <br />Tom nshlp <br />Range <br />Ixitltude <br />I I NORTH <br />DEG <br />MIN SEC <br />w w MATERIAL ! INTERNAL GAUGE <br />Z a DIAMETER OR WALL <br />LOCATION SKETCH <br />NORTH <br />q& <br />v <br />•�1 <br />V' <br />Parcel <br />Section <br />Longitude IWEST <br />DEG MiN SEC <br />vi ` KCw'a., <br />MW �b <br />a <br />W <br />�GTII ITl { <br />NEW WELL <br />MODIFICA11-14 PAn <br />Deepen <br />Other (Speclfyl <br />DESTROY (Describe <br />Procedures and Marginal. <br />Under GEOLOGIC LOG <br />PLANNED USES (� 1 <br />WATER SUPPLY <br />Dcmestic _ Put)hc <br />Irrigation — Indus�t,r/Iaal <br />MONITORING <br />TEST WELL _ <br />CATHODIC PROTECTION _ <br />HEAT EXCHANGE — <br />DIRECT PUSH _ <br />INJECTION <br />VAPOR EXTRACTION <br />SPARGING — <br />SOUTH PEMEDIATION <br />Illustrate or Describe Datauee of IS ell from Rowh Bndelij ct OTHER (SPECIFY) Fences RtUrs etc and attach a map L 5 addltumal paper if <br />necestanJ PLEASE BE ACC GR.ITE Z C011PLETE <br />WATER LEVEL & IIELD OF COMPLETED HELL <br />DEPTH TO FIRST WATER SS (Ft) BELOW SURFACE <br />DEPTH OF STATIC L <br />WATER LEVE 'q0 <br />& DATE MEASURED -3 b <br />ESTIMATED YIELD " (GPM) & TEST TYPE <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br />Nlay not be reps esentata e of a L ell's long-tuwn yield <br />D%%R IIS RE'" 1197 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />CASING (S) <br />DEPTH <br />ANNULAR NIlTER1-1L <br />DEPTH <br />FROM SURFACE <br />BORE <br />HOLE <br />FROM SURFACE <br />TYPE (::) <br />TYPE <br />CE BEN <br />MENT TOWTE FILL FILTER PACK <br />w w MATERIAL ! INTERNAL GAUGE <br />Z a DIAMETER OR WALL <br />SLOT SIZE <br />IF ANY <br />Ft to Ft <br />{Inches ) <br />w w <br />to c� _ <br />GRADE <br />{Inched THICKNESS <br />(Inches)(, <br />Ft to Ft <br />(TYPElSIZE) <br />-r) { ,�) ( f✓. ) <br />- <br />G Z c d <br />I <br />1 <br />4 [ <br />t <br />, <br />ATTACHMENTS <br />t <br />CERTIFICATION STATEMENT <br />I the undersigned certify that this report is complete <br />and accurate to the best of my knowledge and belief <br />Geologic Log <br />` [ It <br />V 4 GU <br />__ _ Well Construction Diagram <br />NAME fPfR50N FIRM OR CORPCRATIONI (TYPED OR TEDI <br />- <br />Geophysical Lcgfs) <br />v 1 CA q q S -7 r <br />o <br />t`o <br />SotilWater Chemical Analyses <br />Ct STATE ZIP <br />other <br />ABBAESS <br />$04LERJAUTrIORIZED <br />3 14 � 1 <br />ATTACH ADDfTJONAf lNFOAMATfON 1F 1T EXISTS <br />Signed 4.L REPR T IYE <br />DATE 51GNED C 57 UCENSE NUMBER <br />D%%R IIS RE'" 1197 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />