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ORIGINAL "1J N )' STATE OF CALIFORNJA DWR USE ONLY DO NOT FILL IN <br /> File with DWR ; \ ;LL COMPLETION REPORT <br /> IPage ` Of��� t y �� Refer to Instruction PamphletSTATE WELL NOJSTATION NO. <br /> Owner's Well No. "0- 729920 0 <br /> Date Work Began ~Da Ended 7-11-00 LATITUDE LONGITUDE <br /> Local Permit Agency S G` �-S O O - APNITRSIOTI <br /> HEFI <br /> Permit No. d 0 $ Permit Date <br /> GEOLOGIC LOG WELL OWNER///(rte <br /> ORIENTATION (✓) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Narne `, <br /> Yke� +_`� <br /> DRILLING7 <br /> DEPTH FROM METHOD FLUID, Maili Add ess <br /> SURFACE DESCRIPTION 14 V= <br /> Ft. to FL .Describe material, grain Size, color, etc. CITY ON STATE ZIP <br /> EL L CAT <br /> Address 1141 Vb <br /> ' City <br /> County O <br /> APN Book Page Parcel <br /> Township "'Rang a Section <br /> Latitude I I NORTH Longitude I l wesT <br /> DEG. MIN. SEC. DEG, MIN- SEC. <br /> ` r LOCATION SKETCH ACTIVITY (2!�.) <br /> I I NORTH — NEW WELL <br /> MODIFICATIONIREPAIR <br /> I I <br /> — Deepen <br /> Other(Specify) <br /> J I <br /> r <br /> DESTROY(Describe <br /> Procedures and Materiais <br /> Under"GEOLOGIC LOG') <br /> PLANNED USES (t) <br /> i I - WATER SUPPLY <br /> Domestic Public <br /> � Irrigation � Industria <br /> 3- <br /> I I W W MONITORING <br /> I 1 <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> I I HEAT EXCHANGE <br /> - DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGING <br /> SOUTH REMEDIATION <br /> 111astrale or Describe Distance r f Well from Rands,Bnidtngs, <br /> Fences,Ricers,etc.and attach a ma Use adrfitionaf y"per if OTHER(SPECIFY) <br /> neerssanj.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> ' I DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> ` WATER LEVEL (FL)&DATE MEASURED <br /> I <br /> ESTIMATED YIELD " (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) r "May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE(} FROM SURFACE TYPE <br /> HOLE <br /> DIA. x Z a l MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BE <br /> FILTER PACK <br /> (inches) z w � a GRADE DIAMETER OR WALL IF ANY MEPTT TONITF FILL ITER PA <br /> Ft. to Ft. m {Inches) THICKNESS (Inches) Ft. to FL ( ) <br /> I <br /> I � <br /> I I <br /> I <br /> I I <br /> I � <br /> ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> I,the undersi ned,certify that this report is mplete and accurate to the best of my knowledge and belief. <br /> Geologic Log V V /q <br /> Well Construction Diagram NAME N <br /> _ Geophysical Log(s) ,^/(PERSON, FIRM, OR CORPORATION) YPP,ED UD UR PRIWED) <br /> _ Soil/Water Chemical Analyses �D ����W <br /> ADDRESSCITY /7/� STATE ZIP <br /> TI ,f�^/� r ,D'" <br /> / <br /> IONAL WFORMATfON, IF fT EXISTS. Signed ATTACH ADDITIONAL W£t IELE ADTH9R D REPRESENTATIVE DATE SIGNED C-57 LICENSE NUM8£R <br /> DWR tas JIM,.iI-g. IF ADDITIONAL SPACE S NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />