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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For I�.ocal Requirements WELL COMPLETION REPORT <br /> Page of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No- 1098941 <br /> Date Work Began 1, Ended `, t~ ~' LATITUDE LONGITUDE <br /> Local Permit Agenev <br /> APN/TRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG ^!� WELL OWNER <br /> ORIENTATION VERTICAL i HORIZONTAL —ANGLE —(SPECIFY) Name— <br /> DRILLING <br /> +dale DRILLING <br /> DEPTH FROM METHOD �--� �'' FLUID Mailing Address _.. <br /> SURFACE,, DESCRIPTION <br /> Ft. to Ft. Describe material, grain size, color, c't t'. CITY STATE ZIP <br /> WELL LOCATION <br /> ' Address <br /> r Cit <br /> COUnty - <br /> �.. -2- <br /> APN rook `z Page Parcel <br /> Township Range Section <br /> Lat I N Long Nl <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH .ACTIVITY (—I) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> _ Deepen <br /> _ Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> A USES(z') <br /> "•1{ �2", WATER SUPPLY <br /> Domestic Public <br /> F � Irrigation Industrial <br /> CnH <br /> I¢ MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> • ,• ^'•• DIRECT PUSH <br /> T <br /> Ir INJECTION <br /> �7� <,,•, ```.� VAPOR EXTRACTION — <br /> c <br /> I I SPARGING <br /> i SOUTH REMEDIATION <br /> I16estrale or Describe Distance of Well Roads,Buildings, <br /> Fences,Rivers,etc.and attach d maap Use additional paper if OTHER(SPECIFY)—_ <br /> necessary.PLEASE BE AVCURATE dt COMPLETE. <br /> I I <br /> WATER L�Vy,� & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER''t�' (Ft.) BELOW�Sl9RFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (,rkWTEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> _r <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE FROM SURFACE TYPE <br /> DIA. x z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN. <br /> (inches) z w f� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m v (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> I I I <br /> I <br /> I I <br /> I <br /> I I <br /> I I <br /> ATTACHMENTS (�) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — Geophysical Log(s) ) ' <br /> Soil/Water Chemical Analyses { — - <br /> ADDRESS CITY STATE III' <br /> Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> 'DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />