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ORIGINAL r. �� J STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR-� :,t . ,/ :LL COMPLETION REPORT <br /> Page�Ofl_L_„F{ 1 t " A I Refer to Instruction Pamphlet STATE WELL NO.ISTATSON NO. <br /> Owner's elled No. 729924 <br /> Date Work Began "" $ y�Ended LATITUDE LONGITUDE <br /> Local Permit Agency 5 "S APNITRSIOTH ER <br /> Permit No. 00 A _ —Permit Date <br /> GEOLOGIC LOG J{fy /W�jEM1LL OWNER <br /> ORIENTATION —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING Maili Ad eS5 <br /> DEPTH FROM METHOD FLUID `O <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe matCrfal, graill Size, color, etC. CITY STATE ZIP <br /> —E L I TIO <br /> I I Address <br /> City J7V 69- ral <br /> I I - County k <br /> APN BOOK Page Parcel <br /> 19vI I Township Range Section <br /> I I � Latitude I I NORTH Longitude I I _ WEST <br /> I I �/" ♦ DEG- MIN. SEC. DEG. MIN, SEC. <br /> V LOCATION SKETCH ACTIVITY f=J <br /> I I NORTH — NEW WELL <br /> I F MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> I , <br /> I I - X DESTROY(Describe <br /> Procedures and Maleriafs <br /> I I Under"GEOLOGIC LOG') <br /> PLANNED USES (2f) <br /> WATER SUPPLY <br /> Domestic Public <br /> I I F _ Inigation — Inclust,ial <br /> I I W ¢ MONITORING— <br /> LU <br /> I I <br /> TEST WELL <br /> I I CATHODIC PROTECTION <br /> HEAT EXCHANGE— <br /> 1 <br /> DIRECT PUSH <br /> E I <br /> INJECTION <br /> E I VAPOR EXTRACTION <br /> F I SPARRING_,. <br /> SOUTH REMEDIATION <br /> Illesirrrte or Describe Disim,ce of 1Velr from Roads,Brli r Ings, <br /> I F Fenccs Ricers,etc.and attach n mrip Ise additional priper if OTHER(SPECIFY)— <br /> necessanj.PLEASE BE ACCURATE&COMPLETE. <br /> I I WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> I F <br /> - DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I i DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&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) May not be representative of a well's long-term yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE( <br /> FROM SURFACE TYPE <br /> HOLE <br /> DIA- Y ¢ a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- FILTER PACK <br /> (Inches) z �++ =r GRADE DIAMETER OR WALL W ANY MET TONITE FILL <br /> Ft. to Ft. m (Inches) THICKNESS (inches) FL to Ft. (TYPFISIZE) <br /> E I <br /> I <br /> I <br /> I E <br /> I E <br /> I E <br /> ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> I, the undersigned,certify <br /> that this re ortt iiss/coo�,m,,plete and accurate to the best of <br /> my knowledge and belief. <br /> - Geologicell Construction oDiagram NAME /��/�`�r (4" `� '� • y,�" <br /> (PER N, FIR�Itt,, OR CORPORA ION) [TYPED OR PRINTED) <br /> — Geophysical Logic L 'J,,,_/�1' ;� /" ,�.A ` C,17 <br /> Soil/Water Chemical Analyses e fGy'� �'C r y(�, ({'I'`�[ � (< <br /> — Other ADDRESS CITY STATEZIP <br /> ATTACH ADDITIONAL INFORMATION, IF 1T EXISTS. Signed wC_OD <br /> DRILLERIAUTK ED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> ir 41 <br /> DMIR 188 HEV- 11-9IF ADDITIONAL SPACE IS NEEDEI5, USE NEXT CONSECUTIVELY NUMBERED FORM <br />