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ORIGINAL <br />Pile with DWR <br />Page __L of I <br />O.vner's Well No <br />Date NG ork Began. <br />Local Pertnit Ag <br />' Permit No <br />ORIENTATION (2L) <br />SURFACE <br />FL to <br />STATE OF CALIFOR\lA <br />WELL COMPLETION REPORT <br />Refer to Instructeon PaMp)tlet <br />r 4 2 Ended (ZQ QNo 729639 <br />Permit Date <br />GEOLOGIC LOG <br />VERTICAL H RIZONTAL -ANGLE -(SPECIFY) <br />DRILLING <br />METHOD FLUID <br />DESCRIPTION <br />Describe material grain size color etc <br />to t <br />I ZS' 4 <br />I 1 <br />I r <br />I 1 <br />I 1 <br />1 1 <br />1 I <br />1 <br />I I <br />I <br />I 1 <br />i I <br />I I <br />1 I <br />I <br />1 I <br />I I <br />I 1 <br />TOTAL DEPTH OF BORING (Feet) <br />TOTAL DEPTH OF COMPLETED LI ELL�j(Feet) <br />STATE WELL NO/STATION NO <br />LATITUDE LONGITUDE <br />APNITRSlOTHER <br />WELL OWNER <br />Address 10 1 W <br />City <br />Countv Sa Ift SST <br />APN Book Page <br />Tvxnshtp Range <br />Latitude _ I i NORTH <br />DEG MIN SEC <br />LOCATION SKETCH <br />NORTH <br />�J <br />V <br />V) <br />Lu <br />Lu <br />651, , VE -t <br />LOW <br />�aIL'!;'i <br />�i <br />i 1 <br />Parcel <br />BORE <br />HOLE <br />DIA <br />(Inches} <br />Section <br />TYPE (� ) <br />'' <br />x w p R MATERIAL 7 <br />iL GRADE <br />LL <br />Longitude <br />I I WEST <br />Fl. to Ft <br />DEG MIN SEC <br />to <br />CTIN ITl (:) <br />G <br />NEW WELL <br />MOOIFICATIONIREPAIR <br />V ` - vie_ L 1 i <br />Deepen <br />Other (Specify) <br />DESTROY f0ascribe <br />Procedures and Matana+. <br />Linder GEOLOGIC LOG l <br />PLANNED LSES (.!L) <br />WATER SUPPLY <br />Domestic Public <br />Irrigation Industria <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 />llinstratc or Dewnbe Distance of )Sefl froJll Road, Bnddln�s <br />Fences Rt ers etc ana nosyy Lrse additional yaper'f OTHER (SPECIFY) <br />necessonf PLEASE BE ACCLRAIE d: C011PLETE <br />`TATER LEVEL & YIELD OF COMPLETED WELL <br />DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br />DEPTH OF STATIC <br />WATER LEVEL (Ft) & DATE MEASURED <br />ESTIMATED YIELD (GPM) & TEST TYPE <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br />`Alay not be repyesentatite of a wells long-term yield <br />DEPTH <br />FROM SURFACE <br />BORE <br />HOLE <br />DIA <br />(Inches} <br />CASING (S) <br />TYPE (� ) <br />'' <br />x w p R MATERIAL 7 <br />iL GRADE <br />LL <br />INTERNAL GAUGE <br />DIAMETER OR WALL <br />(Inches) THICKNESS <br />SLOT SIZE <br />IF ANY <br />(inches) <br />Fl. to Ft <br />p 1 � <br />to <br />UG <br />G <br />i <br />10 <br />VG5c,4 <br />40 <br />0.v2-0 <br />I <br />1 <br />ATTACHMENTS (✓) CERTIFICA <br />I, the undersigned, certify 0 <br />— Geologic Log \/ <br />a w r <br />— Well Construction Diagram NAME (PERSON FIRM OR CORPORA <br />— Geophysical Log(s) <br />— <br />Soil/Water Chemical Analyses <br />Al}ORE55 <br />— other <br />ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br />Lt BRIILER/AUTHOR! <br />this report Is complet <br />IIIIIne) <br />DEPTH I ANNLLAR NIATERIkL <br />FROM SURFACE I _ TYPE <br />CE BEN FILTER PACK <br />MENT ITONITE1 FILL <br />Ft to FI (Zr) (L) (�) (TYPEISIZE) <br />1 SW q <br />6 i 38 I ✓ <br />I <br />1 -- <br />TION STATEMENT <br />3 and accurate to the best of my knowledge and belief <br />CITY STATE IIF <br />_ <br />3116 oa 720Ro� <br />DATE SIGNED C 57 LICENSE NUMBER <br />DLIR VS RE% It 97- IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />