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ORIGINALCrr`„`'r] ��� STATF. OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> I L <br /> r File Wit DWR <br /> LL COMPLETION REPORT <br /> Page of� Refer to Instrttetrio�n(Pamphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well No.—At W-3� C] 1 No. <br /> L+7 J L ❑ ❑ <br /> Date Work Began + V�O✓ ]1.d,d ■w` tet/ <br /> Local Permit AgenC � <br /> Permit No. A.3 $oZ Permit Date_ 170_010 <br /> 70^OD APNfTRSlOTHER <br /> GEOLOGIC LOG -,WELL OWNER <br /> —VERTICAL HORIZONTAL ANGLE SPECIFY Name �69 Y •-�' c <br /> ORIENTATION {�) —(SPECIFY)) <br /> 9 A_ 'a�ParI C�� LL <br /> DRILLING1 <br /> ailin�"Address <br /> DEPTH <br /> SURFACE <br /> METHOD FLUID .114 <br /> `CITY - STATE ZIP <br /> Ft. to Ft. .' <br /> - Describe material, grain'si:e, color, etc -.'. <br /> LOCAT�GGLL QN <br /> ' Address // uu <br /> I � <br /> County ' rSLI h oLL 4/pi , – — <br /> APN Book Page Parcel <br /> N Rang E <br /> SectionTowiisirP <br /> I I _ NORTH WEST <br /> O <br /> Longitude t I <br /> atttude I I pp�I <br /> n, DEG- MIN. SEC. b- DEG. MIN. SEC. <br /> 1 I - <br /> LOCATION SKETCH ACTIVITY (:) <br /> a I - NORTH NEW WELL <br /> MODIFICATTONIREPAIR <br /> I I •'� - Deepen <br /> -3 - - - Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> PLANNED USES ( :L) <br /> i <br /> WATER SUPPLY <br /> Domestic Public <br /> F_ F Irrigation � Endustrial <br /> W w MONITORING <br /> I r TEST WELL <br /> I r CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> I r <br /> DIRECT PUSH <br /> INJECTION <br /> ' VAPOR EXTRACTION <br /> I r SPARGING <br /> i SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> i r Fences,Ricers,etc.and attach a;nap Use additional paper if OTHER(SPECIFY)— <br /> necessary,PLEASE BE ACCURATE&COMPLETE. <br /> E WATER LEVEL'& YIELD OF COMPLETED WELL <br /> I i <br /> i I DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> r ESTIMATED YIELD' (GPM) &TEST TYPE <br /> TOTAL DEPTH'OF BORING (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <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 BORE- <br /> HOLE TYPE(�} FROM SURFACE (ypE <br /> DEA. Y z n MATERIAL! INTERNAL GAUGE SLOT SIZE CIE BEN- <br /> (Inches) z w zr - GRADE DIAMETER OR WALL IF ANY .MENT TONITE FILL FILTER PACK I <br /> Ft. to Ft. gm o o0= __ (Inches) THICKNESS (inches) Ft. to Ft. (TYPEISIZE) <br /> Iz I I <br /> I 1 <br /> I 1 <br /> 1 I <br /> I I <br /> I <br /> I I <br /> ATTACHMENTS (.!L) CERTIFICATION STATEMENT <br /> i I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> _ Geologic Log fA C hrm <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORAT N) (TYPED OR PRINTED) <br /> Geophysical Log(s) r <br /> SoillWater Chemical Analyses <br /> Other ADDRESS r /�►JI CITY <br /> J7/y�-Av STATE /ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF tT EXISTS. Signed r I "` " —-p0 _ ��` <br /> W DRILLERIAUTH 0 RE RESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 BEV. 11-97 IF ADDITIONAL SPAC IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />