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ORIGINAL <br />File with DWR <br />Page i of f <br />Ownees ,ii No <br />Date N Oork Began <br />~ Local Permit Ag" <br />' Permit No _ <br />L <br />ORIENTATION (:�: ) <br />DEPTH FROM <br />STJ,TE OF CALIFORNIA <br />WELL COMPLETION REPORT <br />aero to Instruction Pantnl,fet <br />GEOLOGIC LOG <br />ZERT3CAL HO ZONTAL — ANGLE <br />DRILLING �/1{ <br />METHOD FLUID <br />DESCRIPTIO\ <br />Describe material gram size color etc <br />L .:7 G , rLAJ <br />F , 4- <br />qj <br />6q 51 jV <br />A; t <br />$ i t 1 1 j7j 5 { <br />I <br />Ilk <br />I I <br />t , <br />I I <br />I t <br />i <br />I I <br />F i <br />, <br />1 t <br />1 , <br />, <br />I I <br />F F <br />, I <br />T0i DEPTH OF BORT\G {Feet) <br />TOTAL DEPTH OF COMPLETED HELL (Feet} <br />STATE WELL NO /STATION NO <br />LATITUDE LONGITUDE <br />APNITRSfOTHER <br />ELL 0""'ER <br />1 <br />(SPECIFY) `anie <br />Mailing Address <br />CITY STATE ZIP <br />V ELL LOCATIO\ <br />Address !Y7 <br />I- W =_xtr Si <br />CaN <br />(S) <br />County <br />DEPTH <br />APN Boot. <br />Page <br />Tovniship <br />Range <br />Latitude <br />F r NORTH__ <br />DEG <br />MIN. SEC <br />MATERIALI INTERNAL GAUGE <br />GRADE DIAMETER OR WALL <br />LOC-ktlO\ SKETCH <br />NORTH <br />q-7 / <br />Parcel <br />Section <br />Longitude 1 I WEST <br />DEG MIN SEC <br />�ICTI1IT1 (:) — <br />NEw WELL <br />MOOIFICATiON/REPAIR <br />Deepen <br />Other (Specify) <br />DESTROY (Describe <br />Procedures and Materials <br />{Under GEOLOGIC LOG 1 <br />PLANNED USES t ) <br />WATER SUPPLY <br />.^ Domestic Poi <br />Irrigation Industria <br />H <br />4 MONITORING _ <br />w <br />TEST WELL _ <br />CATHODIC PROTECTION <br />HEATEXCHANGE— <br />DIRECT PUSH — <br />INJECTION <br />VAPOR EXTRACTION <br />SPARGING _ <br />SOUTH REMEOIATION _ <br />11luvtrrrte or Descri& Dlstmtce of hell front Roads Rrtrldili <br />Fences R,ters etc and attach a nulp G'se addlNona! pnNer rf OTHER (SPECIFY) _ <br />rrecessanf PLEASE BE ACCUR� E L COUPLET <br />1, CATER LEVEL & IIELD OF COMPLETED LIELL <br />DEPTH TO FIRST WATER 59 ri BELOW SURFACE <br />DEPTH OF STATIC <br />WATER LEVEL (FI) & DATE MEASURED <br />ESTIMATED YIELD (GPM) & TEST TYPE <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br />May not be rep esentatl,,e of a :!.elft long-rerwi yield <br />DUR IIA REI, It 97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />(S) <br />DEPTH <br />W%ULAR N11TERIIIL <br />DEPTHCASING <br />FROM SURFACE <br />BORE <br />HOLE <br />FROM SURFACE TYPE <br />TYPE() <br />DIA <br />(Inches) <br />x w o: a <br />a w Z2 . <br />MATERIALI INTERNAL GAUGE <br />GRADE DIAMETER OR WALL <br />SLOT SIZE <br />IF ANY <br />CE BFN <br />MENT TONITE FILL FILTER PACK <br />Ft to Ft <br />m N 8Q = <br />(inches) THICKNESS <br />(inches) <br />Ft to F! <br />(TYPEISIZ>ti) <br />i <br />O <br />x <br />a <br />2� <br />✓ <br />O,b20 <br />i 2 <br />tS <br />F <br />I <br />t <br />ATTACH,NIE\TS (.!:L) <br />i <br />CERTIFICATION STATELME\T <br />[ the undersignedthat this re art is complete and accurate to the best of my knowledge and belief <br />— Geologic Log <br />�certify <br />V Or-,� <br />( ` <br />Well Construction Diagram <br />NAME (PERSON FIRM OR CORF4RAIIi (TYPED OR EO) <br />U <br />Geophysical Logs) <br />1r <br />`r 15 <br />e Q j <br />Cr 1 1 q§'-71 <br />_ SoIVWater Chemical Analyses <br />Q16 <br />AIIDRESS <br />CITY <br />SPATE <br />T Oilier <br />4r <br />a 1 <br />+� �2QtP [,� <br />3/e -7 Z0"o <br />ATTACH ADDITIONAL INFORMATION IF IT EXl5TS <br />Signed <br />ELL ORILLERlAUTHOAt PRESEtI <br />VE <br />/ <br />pAT STONE C 57 LICENSE NUMBER <br />DUR IIA REI, It 97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />