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TRIPLICATE STATE OF CALIFORNIA DwR USE ONLY — DO NOT FILL IN <br /> Owner's Copy WELL COMPLETION REPORT <br /> Page L_of Refer to Instruction Pamphlet STATE WELL NO ISTATION NO <br /> Owner's Well No A; 5 NoT QEiii 0 <br /> Date Work Began ;<-i ,l , Ended? -1 v Q LATITUDE LONGITUDE <br /> Local Permit A encx it l € <br /> 71 <br /> Permit No ),_ x - _- — _Pei.t Date t'I APN/Tfl510FHERA <br /> GEOLOGIC LOC .S <. ( LL OWNER <br /> ORIENTATION (�) - VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Na]rm ` } <br /> DRILLING �q Mailsza A s ' <br /> DEP�IAC�E <br /> METHOD 1-�! I", ^����I r`�f •� FLUID -.� '� <br /> SDESCRIPTION \�',• a e <br /> Ft Describe material grain size color etG�\, \\�. 'CITY � 4 STATE ZIP <br /> 1 ELL LOCATION <br /> it r ' t ?x 1� r <br /> I I t l •C r �un J� � �'`1 . <br /> ``•"\� -�',�'� { N Book age Parcel <br /> 4 C . <br /> ' ' ` ='>• TOWx"rsing` Range Section <br /> I I \ -VaSCvdeNORTH Longitude I r wes7 <br /> DEG MIN SEC D&G MIN SEC <br /> L \ LOCATION SKETCH ACTIVITY (�) <br /> Yj <br /> i � � �\ < �s NORTH — NEW WELL <br /> MCDIFIGA7IONlREPAIR <br /> \\ > Deepen <br /> Other(Specify) <br /> V 9 I )j <br /> I r i �r\lC v _,._, DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> PLANNED USES (:) <br /> WATER SUPPLY <br /> �,. Domestic Public <br /> Irrigation — Industrial <br /> En H <br /> wMONITORING <br /> I I TEST WELL— <br /> CATHODIC <br /> TiON <br /> HEATT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION— <br /> 4` VAPOR EXTRACTION <br /> I I SPARGING <br /> i I SOUTH REMEDIATION <br /> Illustrate or.Describe Distance of Wall from Roads Buildings OTHER(SPECIFY) <br /> Fences Rkem etc and attach a map Use additional per rf <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> I e <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I r <br /> I r DEPTH TO FIRST WATER (Ft) BELOW SURFACE: <br /> i DEPTH OF STATIC <br /> WATER LEVEL (FI)&DATE MEASURED <br /> ' ESTIMATED YIELD• (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN _ (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL S —(Feet) May not be representative of a well's lars -term yield <br /> DEPTH BORE <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> � <br /> FROM SURFACE HOLE TYPE(.::L) FROM SURFACE TYPE <br /> DIA Y z a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BEN <br /> Slnches) z w a GRADE DIAMETER OR WALL IF ANY MENT�TONITE FILL FILTER PACK <br /> Ft to Ft 0 � (Inches) THICKNESS (Inches} FL to Ft (y) (�) {�) (TYPE/SIZE) <br /> � W <br /> I / I <br /> ' L <br /> I <br /> I I <br /> I I <br /> I I <br /> ATTACHMENTS (z�) CERTIFICAVON STATEMENT <br />. I,the undersl ned certify that this re ort Is complete and accurate to the best of my knowledge and belief <br /> Geologic Lo <br /> Well Construction Diagram NAME <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) I (i <br /> Sotl/Water Chemical Analyses `':4 ; (tillor t'( <br /> Other ADORE r I ( CITY Y STATE'" ZIP <br /> ed s <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signf WELL 0 ILLERIAl1TH0RIZED R RESE ATIYE ) OATS SICsNEO C 57 LICENSE N BER <br /> own 188 REV 11 87 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />