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ORIGINAL <br />Fiie with DWR <br />Page 1 of 1 <br />Owner's NVeii No <br />Date Worl, Began <br />Local Permit Ag( <br />. Perinit No _ <br />ORIENTATION (z::.) <br />STATE OF CALIFOR\IA <br />WELL COMPLETION REPORT <br />Rcfer to Instruction Pamphlet <br />STATE WELL NO /STATION NO <br />LATITUDE LONGITUDE <br />APN/TRSIOTHER <br />civ � a u • l rt:rillll Lace - - — <br />/ GEOLOGIC LOG <br />yLL O VAI <br />VERTICAL HORIZONTAL —ANGLE —(SPECIFY) Name <br />C RILLINCs <br />METHOD FLUID c <br />4{ai Ina Ad 55 w <br />DESCRIPTION <br />Descrtbe material grain size color etc CITY STATE ZIP <br />IIELL• LgO;'►TIO\ <br />! ' 1i 1' <br />1 t6 7,t + wl G <br />i I <br />I <br />I 1 <br />1 I <br />[ <br />t t <br />I 1 <br />I I <br />t <br />[ [ <br />[ I <br />1 <br />I I <br />t <br />[ I <br />[ F <br />1 i <br />TOTAL DEPTH OF 8081\CT(Feet) <br />TOTAL DEPTH OF COMPLETED WELL 6,5, (Feet) <br />Address <br />30 W Ise <br />City <br />CASING <br />COtinh <br />�l <br />APN Book <br />Page <br />Township <br />Range <br />Latitude <br />NORTH <br />DEG <br />MIN SEC <br />MO OIFICATICNIREPAIR <br />LOCATION SKETCH <br />NORTH <br />MW -a <br />Parcel <br />BORE <br />HOLE <br />DIAx <br />(Inch"$) <br />Section <br />CASING <br />Longitude <br />WEST <br />DEG MIN SEC <br />INTERNAL GAUGE <br />DIAMETER OR WALL <br />(Inches) THICKNESS <br />TIN ITi (J) <br />Ft to FL <br />NEW WELL <br />MO OIFICATICNIREPAIR <br />— Deepen <br />1 <br />_ Other (Specify) <br />T DESTROY (Descnbe <br />Procedures and Mater+ars <br />Under GEOLOGIC LOG <br />PLANNED USES (2:L) <br />WATER SUPPLY <br />Domestic _ Pubic <br />H Irrigation — Induili <br />4 MONITORING <br />W <br />TEST WELL _ <br />CATHODIC PROTECTION _ <br />HEAT EXCHANGE _ <br />DIRECT PUSH <br />INJECTION <br />VAPOR EXTRACTION <br />SPARGING _ <br />SOUTH REMEDIATION _ <br />111nstrcaL or Ddsenbe Distance of %ell fiivm Roads Buildings <br />Fences Ricers etc and attach a ntnyy Use additional PPaper f OTHER (SPECIFY) _ <br />necessanf PLEASE BE ACCVKV E L- C011FLETE <br />NATER LEVEL bt YIELD OF COMPLETED WELL <br />DEPTH TO FIRST WATER 65' -7 (Ft) BELOW SURFACE <br />DEPTH OF STATIC 96, %t <br />WATER LEVEL (Ft) & DATE MEASURED <br />ESTIMATED YIELD (GPM) & TEST TYPE <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br />Alay not be rep?esentattre of a zLell's long-tet-pn yield <br />DEPTH <br />FROM SURFACE <br />BORE <br />HOLE <br />DIAx <br />(Inch"$) <br />CASING <br />(S) <br />TYPE (.!!L) <br />z ¢ a MATERIAL! <br />a� a GRADE <br />m U <br />INTERNAL GAUGE <br />DIAMETER OR WALL <br />(Inches) THICKNESS <br />SLOT SIZE <br />IF ANY <br />(laches) <br />Ft to FL <br />a <br />vc <br />1 <br />v'G2_ <br />v <br />0,02V <br />I <br />rr; un'rc'trs <br />A1IAt, in. dinINLa tM.I - <br />' I the undersigned certify that this <br />Geologic Log <br />Well Construction Diagram NAME ` 4 4 w ii(PERSON FIRM OR CORPORATION) (t <br />Geophysical Log(s) PnC <br />_ SoIVWater Chemical Analyses <br />ADDRESS <br />Other <br />ATTACH ADOI710NAL INFORMATION IF IT EXISTS Sign WELL DRIL <br />V1A1ITH90iZSE <br />DEPTH ANNULAR MATERIAL <br />FROM SURFACE TYPE <br />CE BEN FILTER PACK <br />MENT TONITE FILL <br />FL to Ft (�) (2�.) (2�-) (TYPFJSIZE) <br />413 66 - <br />TI O <br />TIO\ STATEMENT <br />rt Is complete and accurate to the best of my knowledge and belief <br />DN%R 1',S HE\ tis, IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM <br />i q 6-7) <br />STATE TIP <br />•7 Z OGID 4I <br />