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'11— <br />ORIGINAL <br />File with DWR <br />Hage I of I <br />Owner's Well No .� <br />Date Work )vegan <br />Local Permit Agency <br />' Permit No <br />ORIENTATION (� ) <br />DEPTH FROM <br />SURFACE <br />FL to FL <br />STATE OF CkLIFORNI-k <br />WELL COMPLETION REPORT <br />Refer to Instruction Pamphlet <br />�� GEOLOGIC LOG <br />V VERTICALORIZONTAL — ANGLE — (SPECIFY) <br />DRILLING <br />METHOD FLUID <br />DESCRIPTION <br />Describe material grain size color etc <br />+ v, 4 I <br />v 1 <br />+a <br />441, 0 <br />1 t, t <br />I <br />I t <br />t I <br />1 t <br />1 1 <br />I <br />I 1 <br />1 I <br />I t <br />I <br />I 1 <br />1 I <br />t I <br />I <br />1 I <br />1 <br />1 1 <br />I 1 <br />TOTAL DEPTH OF BORT\G - {Fej),,e <br />TOTAL DEPTH OF COMPLETED `i� ELL (Feet) <br />-- DWR SE NLY — DO NOT FILL IN <br />STATE WELL NOISTATION NO <br />0 <br />LATITUDE LONGITUDE <br />APNITRSIOTHER <br />WELL OWNER <br />aunt' C1,6-'shl con%01,14i <br />Mailing A& ess <br />CITY STATE ZIP <br />HELL LOCATION <br />Ctq _ 60CA1 -- - -- <br />County �r.�.1 . �Olks+: t it <br />APN BookPage <br />To.rnship Range <br />Latitude I I _- ___ NORTH <br />DEG MIN SEC <br />LOCATIO\ SKETCH <br />NORTH <br />r <br />h <br />W <br />Parcel <br />Section <br />Longitude I I WEST <br />DEG MIN SEC <br />CTI! ITl (Z�) <br />NEW WELL <br />MODIF3CATIONIREPAIR <br />.,..., Deepen <br />Other (Specify) <br />w <br />DESTROY f0ascnta <br />Procedures and Marenai, <br />Under GEOLOGIC LOG 1 <br />PLANNED USES (' ) <br />WATER SUPPLY <br />— Domestic Publi^ <br />Irrigation Indus rral <br />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 Describe Dotance of 1% ell (runt Road, Enddaeg-s <br />Ftnces Ricers etc and attach a mayy se additionalriper f OTHER (SPECIFY) <br />nccessanJ PLEASE BE ACCLRATE & CO►fPLETr <br />1FATER LEVEL & YIELD OF COMPLETED N%ELL <br />DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br />DEPTH OF STATIC [ /f l <br />WATER LEVEL ✓ (Ft ) & DATE MEASURED _� / ✓ <br />ESTIMATED YIELD (GPM) & TEST TYPE <br />TEST LENGTH (Mrs) TOTAL ORAWDOWN (Ft) <br />Alay not be tepre3errtatr,e of a cell's long-teryu yield <br />DEPTHCASI\G <br />FROM SURFACE <br />SORE <br />HOLE <br />DIA <br />(inches) <br />(S) <br />TYPE(—) <br />'' <br />x w a MATERIAL I INTERNAL GAUGE <br />z s �� a GRADE DIAMETER OR WALL <br />m N �o LL (Inches) THICKNESS <br />SLOT SIZE <br />IF ANY <br />(tncnes) <br />Ft to Ft <br />rILIO <br />1 <br />0.02-0 <br />' Geologic Log <br />Well Constniapon Diagram <br />— Geophysical Log(s) <br />— SoI Wafer Chemical Analyses <br />— Other <br />A77ACH ADorvONAL INFORMATION IF IT EXISTS <br />I the undersigned certify that this <br />!NAME _ V 4 6() - - <br />ADDRESS <br />DEPTH A%NLLAR MITERIaL <br />FROM SURFACE TYPE <br />CE BEN FILTER PACK <br />MENT ITONITE FILL <br />Ft to Ft (4) (�) (�) (TYPEISIZE) <br />I <br />I <br />CERTIFICAtius 5TAT :*iE'S <br />rt Is complete and accurate to the best of my knowledge and belief <br />P, D )�,)T ?f1616 -D STATE -7 2 —f <br />DNIR thh REV 11197- IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />