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oRiGrNAL 1 Y^ �// STATE OF CALIFORNIA DwR USE ONLY — DO NOT FILL IN <br /> File with DW,R^� tj �-� [6 rLL COMPLETION REPOR <br /> PageA__Off r r Refer to Instruction Parnphlef STATE WELL NO.ISTATION NO, <br /> Owner's Well No. ^1Z No. <br /> Date Work Began 'D -0 7 2 9 9 2 3 <br /> g �1Ended ~[ V - LATITUDE LONGITUDE <br /> Local Permit Agency __ JOH5 <br /> Permit No. OC J Permit Date �� SOD 'APNITRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) 1 G <br /> DRILLING —(sPECIFv) Name u! ✓: <br /> DEPTH FROM METHOD FLUID. Mallin 'Ad e_S§, 1 0' <br /> SURFACE <br /> DESCRIPTION -j^ <br /> FL to FL Describe material, grain siZe, color, etc.', CITY I ` 't •� STATE ZIP <br /> ILE <br /> r ,A.ddress <br /> r I ,,Countys..' -0 Q Iv/"- <br /> -.APN Book Page Parcel <br /> TownshipItange <br /> , Section <br /> "Lai7t6.deNORTH Longitude WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH <br /> NEW WELL <br /> I 1 5 <br /> MODIFICATION/REPAIR <br /> _ - - _ Deepen <br /> I I ! E — Other(Specify) <br /> I (.- <br /> DESTROY(Describe <br /> e , I Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USES (z�) <br /> WATER SUPPLY <br /> I I <br /> Domestic Pubflc <br /> i— _ IrngatioR industrial <br /> I I w ¢ MONITORING <br /> TEST WELL_ 4 <br /> I 1 CATHODIC PROTECTION <br /> - I <br /> 1 I HEAT EXCHANGE <br /> I I DIRECT PUSH <br /> INJECTION <br /> I ! <br /> VAPOR EXTRACTION <br /> I r SPARGING— <br /> I I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well tom Roads,Buildings, <br /> I 1 Fences,Rhers,etc.and attach a Ina} USe ndditionnl poper f OTHER(SPECIFY) . <br /> rlecersany PLEASE BE ACCURATE&COMPLETE. 'I <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 1 <br /> I 1 DEPTH TO FIRST WATER (Fl.)'BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> I I <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Firs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's Ming-term yield. <br /> DEPTH BORE- DEPTH <br /> CASING (S) ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(2L) FROM SURFACE TYPE <br /> DIA. Y z ¢ a MATERIAL? INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (inches) a ¢ �� o GRADE DIAMETER OR WALL $F ANY MENT TONITE FILL ' FILTER PACK <br /> Ft. to Ft. v (Inches) THICKNESS (inches) Ft. to Ft. (TYPE/SIZE) <br /> I <br /> I 1 <br /> 1 1 <br /> I I <br /> 1 I <br /> I I <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — <br /> Geologic Log ��_p /�/%� _ <br /> _ W0 Construction Diagram NAME —LiC-(i/_ ��/ r( tl/YLM/lyi <br /> Geophysical Log(s) <br /> (PERSON, FIRM OR CORPORAT NF (TYPED DR PRINTED) <br /> — <br /> Soil/Water Chemical AnalysesQ-70 <br /> Other <br /> ADDRESS CITY - STATE ZIP <br /> — <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> 9LADROLLIRRIA64THIED REPRESENIATIV - DATE SIGNED C-57 LICENSE NUMBER <br /> M s 188 HEV. 11-97 IF ADDITIONAL SPAVE IS NEEDE , USE NEXT CONSECUTIVELY NUMBERED FORM <br />