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ORIGINAL `r"- (­ !h ) t'� !j STATE OF CALIFORNIA BWR USE ONLY — DO NOT FILL IN <br /> File with DWR,,f,., �. ALL COMPLETION REPORT <br /> Page I Of 1 Lj Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 1111 W+ ! No. 729919 <br /> Date Work Began 9-IS-00 , Ended r q—I$'O0 LATITUDE LONGITUDE <br /> Local Permit Agency ywS <br /> Permit No. O b A.5 Ct 1%APermit Date 1 9--J3-60 APNITRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name u/V y �'1^Vl L�_e <br /> DRILLING <br /> METHOD FLUID Mailing Ad less <br /> DEPTH <br /> DESCRIPTION L 15-1D <br /> FL to Ft. Describe material, grain Sime, color, efc.' CITY STATE ZIP <br /> L L CATIO <br /> ' .Address <br /> ' City <br /> County Qa re 0001 <br /> APN Book Page Parcel <br /> ' Township Range Section <br /> Latitude I I NORTH Longitude I i WEST <br /> DEG. MSN. SEC. DEG- MIN. SEC. <br /> ' ` LOCATION SKETCH ACTIVITY (f) -- <br /> I I - MORTH — NEW WELL <br /> MODIF ICATIONlREPAIH <br /> Deepen <br /> — Other(Specify) <br /> I I <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOO") <br /> PLANNED USES () <br /> r WATER SUPPLY <br /> Domestic Public <br /> Irrigation Industrial <br /> ' r L ¢ MONITORING— <br /> � w <br /> I TEST WELL— <br /> CATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> I I <br /> DIRECT PUSH— <br /> INJECTION— <br /> VAPOR EXTRACTION— <br /> I r SPARGING <br /> i r SOUTH REMEDIATION— <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> i r Fences,Rieers,etc.and attach a rimep '(.Ise additionnl paper if OTHER tSPEClFY)— <br /> necessarxj.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I r <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Fent) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (FL) <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 /> HOLE <br /> FROM SURFACE BORE TYPE() FROM SURFACE TYPE <br /> DIA. Y z ii MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) z w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> FL to Ft. nn ¢ Ft. to Ft. (TYPEISIZE <br /> m v v {Inches) THICKNESS (Inches) (�) (�) ) <br /> m LL <br /> I <br /> � 1 <br /> r <br /> r I <br /> t I <br /> t 1 <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersi ned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — Geologic Log r +h r _C40�I AA �+I <br /> Well Construction Diagram - NAME /sL <br /> (PERSON, FIRM, QR CORPORATION) (TYPED OR PRfNT€D) <br /> — 62 <br /> Geophysical Log(s) 220 pe4*ft,R l � /+ C��j 4 <br /> — SoiUWater Chemical Analyses /fps rlS ` 7 / <br /> Other ADDRESS CITY STATE ZIP <br /> y <br /> Signed S <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. "0111111111110RIZREPRESERTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> D'WR 188 RFV. a-s; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />