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ORIGINAL. <br />Pile with DWR <br />Page i of i <br />Owner's Well No <br />Date Work Began _ <br />Local Permit Ago <br />. Permit No _ <br />ORIENTATION (z�. ) <br />I DEPTH FROM I <br />STATE OF CALIFORNIA <br />WELL COMPLETION REPORT <br />Refer t/ 96 <br />o Inetrr'r]ct[On (PaOtt+Nh(et <br />No <br />�'2 _Ended_ 12-21h1 1 L40 <br />Pen -nit Date <br />GEOLOGIC LOG <br />_VERTICALHORI ONTAL .ANGLE _ <br />DRILLING <br />METHOD FLUID <br />DESCRIPTIO` <br />Describe material _risen size color etc <br />x <br />1 7. 1 r--. k <br />.S '56k <br />12 r,r1-7 <br />r a <br />-7 i 2"; <br />I S i <br />-2 Z I <br />, r <br />I [ <br />I I <br />I I <br />1 [ <br />1 <br />I , <br />1 1 <br />i r <br />I [ <br />, <br />I , <br />s [ <br />I r <br />I <br />I I <br />I I <br />I r <br />[ <br />1 I <br />I [ <br />TOTAL DEPTH OF BORI\C _{Feet) <br />TOTAL DEPTH OF COMPLETED ELL (Feet) <br />D <br />LATITUDE LONGITUDE <br />APNITRSIOTHER <br />ELL 01'NE11 <br />(SPECIFY) Name " Y / <br />� <br />Mia ng Adrlract Pei �e tY <br />CITY STATE ZIP <br />I L CATION <br />Address <br />1191 KSI <br />Ad'�i^ <br />Gt'rK' <br />Ctt% <br />TYPE(''—') <br />MATERIAL I INTERNAL <br />GRADE DIAMETER <br />(Inches) <br />GAUGE <br />OR WALL <br />THICKNESS <br />SLOT SIZE <br />IF ANY <br />(Inches) <br />TYPE <br />FL to Ft <br />Y w ¢ a <br />¢ z� rL <br />c o <br />w <br />COUnt4 <br />-SIT) bfl •I11i1 <br />20 <br />_ <br />AP\ Boot. <br />Pacge <br />Parcel <br />To%nslup <br />Latitude <br />Range <br />I I NORTH <br />Section <br />Longitude <br />I I WEST <br />DEG MIN SEC <br />LOCATION SkETCII <br />DEG MIN SEC <br />CTIIITI (;) — <br />NORTH <br />16'ja <br />NEW WELL <br />I <br />MODIFICATIONIREPAIR <br />— Deepen <br />t <br />— 011ier (Specify) <br />V <br />�J <br />I <br />71 <br />011 <br />r H <br />w <br />$ w <br />" — • f ovv% <br />_ DESTROY (Describe <br />Procedures and Mateoar. <br />Under GEOLOGIC LOG ) <br />PLANED FUSES (4 ) <br />WATER SUPPLY <br />DerrieshC 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 />Ill,rvtrrrtc or pctrrrLc Blstaace of Sie11 frau Runtls HueldrnIs <br />Ft,eCLr RILers etc mrd attach a nlrty t,se additional payer rf OTHER (SPECIFY) „_._ <br />race "anj PLEASE BE ACCLRA E Z COWPLETEE <br />WATER LEN EL & IIELD OF COMPLETED II ELL <br />DEPTH TO FIRST WATER (Ft) BELOW SURF <br />DEPTH OF STATIC <br />WATER LEVEL ) & DATE MEASURED <br />ESTIMATED YIEL (GPM) & TEST TYPE <br />TEST H (Hrs) TOTAL DRAWDOWN (Ft) <br />`,tirty not be I epi e3entati; e of a well's long -tern yield <br />DEPTHCASI\G <br />FROM SURFACE <br />BORE HOLE <br />DIA <br />(Inches) <br />(S) <br />DEPTH <br />FROM SURFACE <br />ANNULAR MATERIAL <br />TYPE(''—') <br />MATERIAL I INTERNAL <br />GRADE DIAMETER <br />(Inches) <br />GAUGE <br />OR WALL <br />THICKNESS <br />SLOT SIZE <br />IF ANY <br />(Inches) <br />TYPE <br />FL to Ft <br />Y w ¢ a <br />¢ z� rL <br />c o <br />w <br />Ft to Ft <br />CE BEN <br />MENT TONITE FILL FILTER PACK <br />(TYPEISIZE} <br />(�) IJ1 (es) <br />20 <br />to <br />I <br />✓ <br />'2 <br />10 <br />DO <br />v\j C <br />-D 20 <br />16'ja <br />I <br />t <br />' <br />ATTACHNIEN LS (2L) <br />' — Geologic Log <br />Well Construction Diagram <br />Geophysical Logs) <br />Sollwater Chemical Analyses <br />Other <br />ArrACH ADDITIONAL INFORMATION IF IT EXISTS <br />the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br />NVAME_ L D0b1 ---- - <br />(PERSON FIRM OR CORPDRATION) (TYPE PRINTED) <br />Po S� <br />'R i4n, CA <br />ADaRE n „ y4j"� (;r T)f Y I LVA"" <br />3I! 6 la STATE ,7 2 OqD <br />AaR L$h BE. 119r IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />