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�rDWR USE ONLY — DO NOT FILL IN <br /> ORIGINALS � 1 '' STATE OF CALIFORNIA E— <br /> Filewith DVI�R� 0 �. 11 , Refer to Instruction �i <br /> LL COMPLETION REPORT <br /> Page_L of� <br /> et STATE WELL NO.ISTATION NO. <br /> �J� � ,I1 ❑ <br /> Owner's Well No. V `7 No ❑2 9 9 2 <br /> Date Work Began Ended a^j`3"b� LATITUDE LONGITUDE <br /> Local Permit Agene s i G P <br /> O� APN/TRSlDTHER <br /> Permit No. 3 Pennit Date R—l 3 <br /> GEOLOGIC LOGttII WELL OWNER <br /> ORIENTATION (•!) —VERTICAL —HORIZONTAL —ANGLE (SPECIFY) Nalene Y:.Y.- v <br /> DRILLINGTot <br /> Mailin rAddres's <br /> METHOD FLUID g <br /> DEPTH FROM � 'j-_,"_.-1 <br /> '_.,�_-1 L <br /> SURFACE DESCRIPTION s STATE ZIP <br /> clTv. <br /> FI. to FL Describe material, grain sire, color, �-.� ,.r"''. `� ``. 1..>` <br /> � ELL OCAT N <br /> r --Md bss <br /> \ t - <br /> I{ <br /> TAPN B <br /> o <br /> ok Page <br /> Parcel <br /> Township Range Secti <br /> r <br /> I I Clr .-- ,, ', ' •. Latitude.. f I No Longitude I I <br /> WEST <br /> NORTH <br /> DEG- MIN. SEC_ DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> I I NORTH - NEW WELL <br /> MOD IFICATIONIREPAIR <br /> - ' _ Deepen <br /> r - _ _ Other(Specify) <br /> DESTROY(Describe <br /> I I Procedures and Materials <br /> Under"GEOLOGIC LOG") <br />` PLANNED USESO <br /> WATER SUPPLY <br /> Domeslic Public <br /> w Irrigation Industrial <br /> F <br /> I I W W MONITORING <br /> I I TEST WELL <br /> r -I CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> I 1 <br /> DIRECT PUSH <br /> s I <br /> INJECTION�.. <br /> F I VAPOR EXTRACTION_ <br /> r I SPARGING <br /> r r SOUTH REMEDIATION_ <br /> Illustrate or Describe Distance of Welf from Rowls,Buildings <br /> F F Fences,Hirers,etc.and attach a amp. Use additional paper if OTHER(SPECIFY)�.. <br /> necessarrf.PLEASE BE ACCURATE&COMPLETE. <br /> e I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 1 <br /> r I DEPTH TO FIRST WATER (Ft.) BELOW SUAFACE <br /> t I DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> 1 1 <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 /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE ()TYPEFROM SURFACE TYPE <br /> DIA. nc = a MATERIAL! INTERNAL GAUGE SLOT SIZE CE- EIEN- <br /> finches) g GRADE. DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> I Ft. to Ft. m o� LL (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> F I <br /> i I <br /> r I <br /> fr I <br /> r I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this re ofrt�is complete and accurate to the,best of my knowledge and belief. <br /> WellGeolCon traction Diagram NAME Log eIJv 41-- h v r • -" ' , <br /> (PERSON, FIRM, OR CORPO ATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) �O _T JAk, v '/ r q� �� <br /> SoiUVJater Chemical Analyses }�� y <br /> ther ADDRESS CITY �/ /� STATE �'ZIIPPP <br /> ATTACH ADDITTIIONAL INFORMATION, IF IT EXISTS. Signed' - r+ l` �'^'�^0V li�,"� <br /> L DRliL AU RtZE REPRESENTATIVE DATE SIGNED C-5I UCENSE NUMBER <br /> D'WE 188 REV. a-sT IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />