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ORIGINAL '—' ; 'r STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN ^--- <br /> File with DWR ' �. 7 LL COMPLETION REPORT <br /> a— <br /> Page I a _`+r�7 %.01' Refer to Instruction Pamphlet STATE WELL NO-ISTATION NO. <br /> Owner's Well No. U -a n No. 729927 LATITUDE ❑ ❑ T <br /> Date Work Began — �d Ended LONGITUDE <br /> Local Permit Agency tf—S <br /> J q T APNITRS1OTHER <br /> Permit No, B D a�� 2;9 Permit Date � _I,3�V V <br /> GEOLOGIC LOG I/ 1/ WELL OWNER <br /> ORIENTATION <br /> ORIENTATION (�) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name if ~ v cl.L L G <br /> DRILLING <br /> DEPTH FROM METHOD FLUID Mail* g Address <br /> SURFACE DESCRIPTIONP-0,1149 <br /> Ft. to FL Describe matei"ial, grain size, Color, etc. CITY STATE ZIP <br /> WEL O TION <br /> Address <br /> 1 city <br /> r 1 G <br /> County <br /> APN Book Page Parcel <br /> Township Range Adg Section <br /> I r Latitude I I NORTH Longitude I I WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> I l <br /> LOCATION SKETCH ACTIVITY (�} -- <br /> 1 NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> 1 r <br /> DESTROY{pescriN <br /> Procedures and Materials <br /> tinder"GEOLOGIC LOG') <br /> PLANNED USES (2�L) <br /> I WATER SUPPLY <br /> Domestic _ Public <br /> � Irrigation Industrial <br /> U r <br /> W I¢ MONTTORING <br /> I I TEST WELL <br /> I I CATHODIC PROTECTON <br /> HEAT EXCHANGE <br /> I 1 DIRECT PUSH <br /> I I INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGING <br /> SOUTH REMEDIATION <br /> 111ustrate or Describe Distance of Well from Roads,Bzdfding.s, <br /> 1 i Fences,Ricers,etc.and attach amap. Use additional paper if OTHER(SPECIFY) <br /> necessarxf.PLEASE BE ACCURATE&COMPLETE. <br /> r I <br /> WATER LEVET. & YIELD OF COMPLETED WELL <br /> r I <br /> e I DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEFTH OF BORING (Feet) TEST LENGTH <br /> {Hrs.)TOTAL DRAWDDWN (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-HOLE TYPE( ') FROM SURFACE TYPE <br /> — <br /> DIA. Y w MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m v v (Inches) THICKNESS (inches) Ft. to Ft. (TYPEISIZE) <br /> 1 1 <br /> 1 1 <br /> 1 r <br /> I 1 <br /> I r <br /> I I <br /> ATTACHMENTS (2�L) CERTIFICATION STATEMENT <br /> I,the undersig ed,certify that this report is complete and accurate to the best o1 my knowledge and belief. <br /> Geologic Log r �J <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATIDNI (TYPED OR PRINTED) <br /> Geophysical Log(s) C �O �} n /T <_ _ -117 7/ <br /> Soil/Water Chemical Analyses !I '1 /[„ � �jf/i (� <br /> Other ADDRESS CITY �h STAT Z1 <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> I <br /> i 6 <br /> WE RILLERIAUTHORI REPRESENTATIYE DATE SIGNED C-57 LICENSE NUMBER <br /> V Or <br /> DIVE 188 REA'_ 11-07 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />