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ORIGINAL ! � '-,, l . ; N r r r STATE OF CALIFORNIA 1— DWR USE ONLY — DO NOT FILL IH <br /> File with DWR. rJ 1, - ;LL COMPLETION REPORT <br /> y Refer to Instruction Pamphlet STATE WELL NO,ISTATEON NO. <br /> Page�of V � _! No. 729922 <br /> Owner's Well No. <br /> Date Work Began q-Is—66—, Ended 1-11-00 LATITUDE LONGITUDE <br /> Local Permit Agency L Fµ —oO pPNlTRSlOTHER <br /> Permit No. �0 3 $ Permit Date <br /> GEOLOGIC LOG WELL OWNER �! <br /> ORIENTATION {�) —VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) N.me C. <br /> DRILLING Mailing Ad re55 <br /> DEPTH FROM CIE VIV-0 <br /> METHOD FLUID g <br /> SURFACE DESCRIPTION <br /> F[, to FL Describe material, grain sive, color, etc. CITY STATE ZIP <br /> LL LOCATI <br /> Address <br /> City <br /> County <br /> i Pi- <br /> hF_%1WD\vVAPN Book Page Parcel <br /> ' Town ,�ship— Range 4� Section <br /> r 16P f at WRV Latitude r I NORTH Longitude I I WEST <br /> DEG. MIN. SFC. DEG. MIN. SEC. <br /> i r ' <br /> LOCATION SKETCH ACTIVITY (�} <br /> [ iwncii . Piva! NORTH _ NEW WELL <br /> ' [ MODIFICATIONIREPAIR <br /> + Irn . _ Deepen <br /> l V _ Other(Specify) <br /> e [ <br /> i <br /> DESTROY(Describe <br /> Procedures and Materials <br /> i <br /> Under"GEOLOGIC LOG") <br /> + r PLANNED USESf—') <br /> WATER SUPPLY <br /> Domestic Public <br /> Irrigation Industrial <br /> F <br /> wMONITORING- <br /> I I TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE— <br /> DIRECT PUSH <br /> INJECTION_ <br /> VAPOR EXTRACTION <br /> SPARGING— <br /> i i SOUTH REMEDIATION <br /> Illustrate or Descrbe Distance of Well from Roark,Buildings, <br /> r i Fences,Risen,etc.and attach a map. Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE '&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> i WATER LEVEL (Ft.)&DATE MEASURED <br /> i 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-HOLE TYPED FROM SURFACE TYPE <br /> DIA. x $ ¢ a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z Oq a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft, m v (Inches} THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> 1 <br /> i I <br /> i <br /> 1 i <br /> ATTACHMENTS (f) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> r� pl� /�A! j`�j J�� If�tt���/�,�1�� <br /> Well Construction Diagram NAME__TO e_Poet %� ^ �!�'V�")r"t ✓�'��1 bAW ejA� "' <br /> (PERSON, FIRM, OR CORPO ION) (TYPED OR PRIMED) <br /> Geophysical Log(s) Z7O t _��� �� nA^n '��` <br /> — Soil/Water Chemical Analyses 1 �/ `. iA Yu+l 6 <br /> ADDRESS CITY STATE ZIP <br /> _ OtherA/1 Ay– <br /> pcw,�0 <br /> ACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed �7 <br /> L DRILL RIAUTH IZED REPRESENTATIVE <br /> TTADATE SIGNED C-57 LICENSE HUMBER <br /> DWR 188 REV. it-s. IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />