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ORIGINAL <br />File with DWR <br />Page i ofJ— <br />Owner's Well No <br />atte N% ori. Began _ <br />at Permit Ag, <br />Permit No _ <br />ORIENTATION (z� ) <br />DEPTH FROM <br />SURFACE <br />Ft to R <br />k l k <br />rr 1 <br />STATE OF CALIFORNIA <br />WELL COMPLETION REPORT <br />Rcfcr to Instruction Famphlct <br />-�- <br />No 729642 <br />! Z' Ended G G <br />cJ�QuqL, tri uw <br />Permit Date —"�`� <br />GEOLOGIC LOC <br />VERTICAL HORIZONTAL _ ANGLE — (SPECIFY) <br />DRILLING / a <br />METHOD `� ` ` --- FLUID <br />DESCRIPTION <br />Describe material grain size color etc <br />Z) I <br />1 1 <br />, 5 I <br />I , <br />1 I <br />I <br />I I <br />1 1 <br />k ! <br />r 1 <br />, 1 <br />I I <br />r I r <br />I 1 , <br />1 <br />I I <br />I I <br />1 i <br />I I <br />r <br />I I <br />I I <br />I r <br />TOTAL DEPTH OF BORING <br />TOTAL DEPTH OF COMPLETED 11 ELL <br />DEPTH BORE <br />FROM SURFACE HOLE <br />DIA ,t w <br />(inches)o- <br />Ft to Ft m <br />LL <br />, <br />I <br />, <br />ATTACH'IENTS (� ) <br />Geologic Log <br />Well Construction Diagram <br />Geophysical Log($) <br />Soil/Water Chemical Analyses <br />_ Other <br />ATTACH ADDITIONAL INFORMATION IF IT EXISTS <br />MATERIAL I <br />GRADE <br />CASING (S) <br />STATE WELL NOISTATION NO <br />11 <br />LATITUDE LONGITUDE <br />APNrTRSIOTHER <br />WELL OWNER <br />Name <br />%failing Ad <br />ess Vin 52y, <br />.4 <br />+f <br />CITY <br />STATE ZIP <br />L <br />CATION <br />Address <br />LU <br />city <br />Count. <br />a <br />AP` Boot. <br />Page <br />Parcel <br />Tovaishtp <br />Range <br />Section <br />Litltude <br />t I NORTH <br />Lonattude <br />k 1 WEST <br />DEG <br />MIN , SEC <br />b DEG MIN SEC <br />LOCATION SkETCH`ACTIN <br />ITl t J) — <br />NORTH <br />NEW WELL <br />MOMFICATIONIREPAIR <br />-7Q . t V19-41 <br />6S <br />Deepen <br />Other {Specify) <br />DESTROY (Describe <br />Procedures and Matenals <br />Under GEOLOGIC LOG l <br />PLANNED LSES (� ) <br />WATER SUPPLY <br />Dome sbe — Pubnc <br />Irrigation _ Industrial <br />F <br />¢ MOMTORtNG — <br />LL <br />TEST WELL — <br />CATHODIC PROTECTION ,_,,. <br />HEAT EXCHANGE — <br />DIRECT PUSH — <br />ENJECTION <br />VAPOR EXTRACTION <br />SPARGING — <br />SOUTH REMEDIATION <br />Ilinstrate or Describe Distance of Neff frtlo, Roods Ba ddincs <br />Fences RILL etc and attach n "' p se adihtaonal�taper f OTHER (SPECIFY) <br />acccssary PLEASE BE ACCURATE d: Co rPLETE <br />HATER LEVEL & IIELD OF COMPLETED «ELL <br />DEPTH TO FIRST WATER (Ft) BELOW SURFA <br />DEPTH OF STATIC <br />WATER LEVEL (F TE MEASURED <br />ESTIMATED YIELD (GPM) a TEST TYPE — _ —_— <br />TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br />) <br />' Alav of be irpiesentati a of a zrell's lout-te-?tt yield <br />INTERNAL GAUGE I SLOT SIZE <br />DIAMETER OR WALL IF ANY <br />(Inches) I THICKNESS (Inches) <br />0 <br />DEPTH ANNULAR MATERIAL <br />FROM SURFACE TYPE <br />CE BEN FILTER PACK <br />MENT TONITE FILL <br />Ft to Ft (2L) (: ) (4) (TYPEISIZE) <br />1 <br />I <br />1 <br />CERTIFICATION( STATEMENT <br />the undersigned, certify that this report is complete and accurate to the best of my Knowledge and belief <br />NAME v o C)(-\11 1VX4 <br />(PERSON FIRM OR CORPORATION) (TYPED OA INTED) , r <br />?710)Vvs�a CA <br />ADDRESS CIiY STATE ZIP <br />DNIR 1S8 REN liy; IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />