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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR «TELL COMPLETION REPORT <br /> Rifer to Instruction Paniphlrt STATE WELL NO./STATION NO. <br /> Page—of ��[:]I <br /> ElOwner's Well No. No. <br /> Date Work Begat] Ended LATITUDE LONGITUDE <br /> Local Permit Agency I I I I I <br /> APN/TRS/OTHER <br /> Permit No. Pern]it Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (:) _VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) <br /> DRILLING Mailing Address <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain .Size, Color, etc. CITY STATE ZIP <br /> \VELL OCATION <br /> Address <br /> ? g Citv <br /> -7 `fid A County <br /> APN Book Page Parcel _ <br /> ST7 Township Rapp Section <br /> :06M Latitude I' • NORTH Longitude I 1 WEST <br /> %O :107 <br /> IO IP�J DEG. MIN. SEC. DEG. M SEC. <br /> LOCATION SKETCH ,� IVITl` (�) <br /> (IO l� \Ct a �,, NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> 1 C Q Deepen <br /> _ Other(Specify) <br /> g ZttQQLA -s t <br /> _ DESTROY[Describe <br /> Z1 1 eG �Q� h Procedures and Materials <br /> 1 J O Under"GEOLOGIC LOG I <br /> 25 PLANNED USES (:) <br /> Q I WATER SUPPLY <br /> ` I _ Domestic Public <br /> am <br /> / ^ t7 Irrigation Inoustnai <br /> r <br /> _ W w MONITORING <br /> 350 3 5 TEST WELL <br /> � ( T3?O 5ct4 �Ay� CATHODIC PROTECTION <br /> 7 <br /> 3�I O s10� � y C f�jU1 HEAT EXCHANGE <br /> ` _ <br /> �[ 1 --_ DIRECT PUSH _. <br /> - T — — INJECTION <br /> VAPOR EXTRACTION — <br /> I SPARGING — <br /> SOUTH REMEDIATION <br /> lllostratr or Dese•rihe Distance of 11'.111trnm Heads.Buildi ig%. <br /> I — 1,wv.s. Rima,,eta and allacli a mop. Lire riddirinunl uper-i( OTHER(SPECIFY) _ <br /> nrccssary.PLEASE BE ACCURATE&COMPLET�. <br /> I � <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> u DEPTH OF STATIC <br /> -- WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING PeeU TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED IVELL 0 (Feet) "A'Iny not be representative of a well's lon r-ter7n yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE TYPE <br /> DIA. Y M ¢o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z wQ av a DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MEAT BEN <br /> (Inches) FILL <br /> Ft. to Ft. v v (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> (�) (:) lam) <br /> t I <br /> t <br /> ATTACHMENTS (2�.) CERTIFICATION STATEMENT <br /> I,the and rsigned,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 /> — Geophysical Log(s) (PERS N, F R CORPORATION) (TYPED OR PRINTED) <br /> _ Soil/Water Chemical Analyses <br /> _ Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR ISS HEV. 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />