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ORI4GINAL ""`�a+ -.! STATE OF CALIFORNIA r— DWR USE ONLY — DO NOT FILL IN <br /> File with DW + � ; :LL COMPLETION REPORT1 1 l I I I I I I I I <br /> Pageof a ^I Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well No. w No. 7 2 9 9 2 6 [1 <br /> 111 1111] <br /> LATITUDE <br /> Date Work Began _ ^D�r- Ended_ ��j$ � LONGITUDE <br /> Isocal Permit Agency `� APNITRSIOTHER <br /> Permit No. <br /> Or��Q a` Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> _ TCel <br /> ORIENTATION (`L) —VERTICAL —HORIZONTAL ANGLE _(SPECIFY) Name <br /> METHOD FLUID DRILLING Nisi Address l� <br /> DEPTH FROM DESCRIPTION C O <br /> SURFACE <br /> FL to Ft. Describe inaterinl, grain size, Color, eto. CITY STATE ZIP <br /> W OCAT N <br /> I I Address <br /> City <br /> I I County 0 N <br /> I r APN Book ��J Page Parcel <br /> ��.-`-=-- <br /> I I Township� Range 6� Section <br /> I I Latitude I NORTH Longitude I I WEST <br /> DEG. WN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (2L) <br /> NORTH NEW WELL <br /> 1 , - MODIFICATIONIREPAIR <br /> Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> �� 11 Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USES (—') <br /> WATER SUPPLY <br /> Domestic Public <br /> F- t_ Irrigation _ €ndustriaT <br /> [ t Lu W MONITORING— <br /> TEST WELL— <br /> CATHODIC PROTECTION— <br /> HEAT EXCHANGE <br /> DIRECT PUSH— <br /> I I INJECTION <br /> VAPOR EXTRACTION— <br /> i SPARGING <br /> SOUTH REMEDIATION— <br /> Ilht.strate or Describe Distance of Well font Roads,Buildings, <br /> t ` <br /> Fences.Ricers,etc and attach a in Use additional ppaper f OTHER(SPECIFY} <br /> necessary.PLEASE BE ACCURATE&CObfPLETE. <br /> t WATER LEVEL & YIELD OF COMPLETED WELL <br /> t <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> ESTIMATED YIELD " (GPM)R TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED 1VELL (Feet) "May not be represematiue of a well's long-terns yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE(') FROM SURFACE TYPE <br /> HOLE <br /> DIA, x w a MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- FILTER PACK <br /> (Inches) z w a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft. to Ft. g v Inches THICKNESS (inches) Ft. to Ft. (TYPE/SIZE) <br /> I <br /> 1 � <br /> 1 � <br /> 1 I 11 <br /> 1 � <br /> ATTACHMENTS (!) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log � __f .,� kf� fs.,�lti / <br /> Well Construction Diagram NAME �[ / <br /> (PERSON, FIRM, OR CORPORA ON) (TYPED OR PRINTED) <br /> — Geophysical Log(s) r�Ii D ?erkrl � jaiqq y 7, <br /> Soil/Water Chemical Analyses p�L <br /> ADDRESS x ��, CITY STATE ZIP <br /> Other {//f �V.! J[��� <br /> ATTACH ADDITfONAL INFORMATION, IF IT EXISTS. Signed TAB <br /> W RILLERi" ED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR IM REV. 11-9; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />