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ORIGINALii; sr\T1; oI c,%I.1Ft)1;�\I,I, DWR USE ONLY — DO NOT FILL IN <br /> File with DWR `TELL COMPLETION REPOT' <br /> Page I of-j— %"W/ Iilfrr ttr llrsfrurtlnl! Yrtrn)rlllet STATE WELL NOISTATION NO. <br /> Owner's Well No. No. 1:1Datc Work Began 5 9 Ended�,§ � g 820313 LATITUDE LONGI7U UE El <br /> Local Perinit Agency 1 I01A P S <br /> Permit No, 0 }�'} Permit Date aPNrTRs orHER <br /> GEOLOGIC LOG NVELL OWNER <br /> ORIENTATION (2::) _VERT€CAL —HORIZONTAL —ANGLE _{SPECIFY) N illlle c 'L r <br /> DRILLING' ll 1� �1 !� [, <br /> DEPTH FROM ksfee <br /> METHOD 9 a r', ;MI !T� Y�FLU3D N Nlading Address_P' v k o X ��3 Zi — <br /> SURFACE DESCRIPT ON CA 95010 <br /> FI. o Ft. <br /> I7rscribe Materied, nrrilr si��r- color- ctr. CITY srnrE z€P <br /> 11'' LO AT10N <br /> Address-140 E g i g r,VAT W q,y <br /> SEt he REb WiiLL cite ock . o <br /> ' ctT�11Tri- 5� a• �� ►L <br /> AP\ Book J_SS-Page 3T0 Parcel <br /> Township Range Section <br /> I I Latitude I I NORTH Lou-itude E WEST <br /> I DEG. MIN. SEC. DEG- MIN. SEC_ <br /> LOCATION SKETCII TIVITY (zL) <br /> I I NORTH NEW WELL <br /> I I G MCUIFICATIONiREPAIR <br /> L <br /> Deeper <br /> I F_ AT t h C �1 p —Other(Specliy} <br /> M !•RP <br /> DESTROY(Describe <br /> Procedures and Materials <br /> I I Under"GEOLOGIC LOG") <br /> PLANNED USES (t I <br /> I WATER SUPPLY <br /> Domestic Public <br /> trrlgation Induslrig/Y/ <br /> U)~ ~ <br /> I I Li 14 MONITORING <br /> I I TEST WELL <br /> I CATHODIC PROTECTION <br /> I I HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> 3 VAPOR EXTRACTION <br /> r , SPARGING <br /> r I SOUTH REMEDIATION <br /> 111?14ratr or Dmcvihe DWIEaec of 11"L41 from Roads,&liltlbl v, <br /> I I Fences,Ritel-s,etc.curd athYlt¢nTa 1. t;w additiunrtl 11uttn=r if OTHER)SPECIFY) <br /> necrssrinl_PLEASE BE ACCURATE c CO3fPLETG. <br /> 1 I <br /> WATER LEVEL & YIELD OF CO\IPLETED WELL <br /> i I DEPTH TO FIRST WATER (Ft.) BELOW SURFACEDEPTH 1 s <br /> I I <br /> WATER OLEVELATIC 01 <br /> 3 (Ft.)&DATE MEASURED l t` 9 7 <br /> ESTIMATED YIELD NA <br /> A (GPM) & TEST TYPE A QA <br /> TOTAL DEPTIf OF ROBING ._--._..��(Feet) TEST LENGTH l�!f (Hrs.)TOTAL DRAWDOWN_...IL&(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL Sy Feet) "AIay not he r-ep-esentatire of a«elh-long-tei-m viclfl. <br /> DEPTH CASING (S) DEPTH ANNULAR h1ATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE(-) FROM SURFACE TYPE <br /> DIA. x z ¢ o- MATERIAL) INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) a zo� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m v o� _�,, (Inches) THICKNESS (inches) FI. to Ft. (TYPE/SIZE) <br /> d 30 PSL L 5 A 40 0 <br /> 30 50 $ eve Z 5ch.41V 0& 10-.. Z S <br /> r <br /> Ikk <br /> i I <br /> 1 I <br /> ATTACHNIENTS (2!�) CERTIFICATION STATEIIENT <br /> I, the undersigned, certify that thts report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log �/ ��YV 1 yW� <br /> Well Construction Diagram NAME V + �-l;11411. 14 G <br /> (PERSON. FIRM, OR CDRPDRATION} (TYPED R PRINTED) <br /> Geophysical Logs) 4' K, <br /> a ` 6 i ^ A 9 4 51-1 <br /> Soil/Water Chemical Analyses ID v 7 <br /> Other S I +,t P 1 I nr ADDRESS CITY q STATE Z€? <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed / _ 120 9 <br /> WELL RILLERlA 0 )ZED R P SENTA IVE DATE SIGNED C-57 LICENSE NUMBER <br /> I71["R IhS HG\'. 11-97 IF ADD3TIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> a,. <br />