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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR t ` �� -' ELL COMPLETION REPORT <br /> Page 01 n ! Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. /"e _ i "°' 7 2 9 9 1 7 11 <br /> Date Work Began y jq^ d Ended R-Jp`b0 LATITUDE LONGITUDE <br /> Local Permit Agency 5j(1 45 11111111111111 <br /> Permit No. D Q a 3 9 S oZ Permit Date 4 -13-00 APNITRSIOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (_!!L) —VERTICAL —HORIZONTAL —ANGLE _SSPECIFY) Name . E e u lya SP.+t/`IJ 1 C2 s 1-tc <br /> DRILLING <br /> DEPTH FROM a <br /> METHOD FLUID Mailin Address <br /> L <br /> SURFACE DESCRIPTION _....girb 1AK -- fl,T1 <br /> FL to Ft. Describe material, grain size, color, etc. CITY STATE Zip <br /> W L L CATION <br /> Address <br /> city '7 Q/_k rnA <br /> rI Ow&IT - County s uVl. JO aG GI -- ----- <br /> ' APN Book Page Parcel <br /> Township Range 166 Section <br /> Latitude I I NORTH Longitude E I WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> r LOCATION SKETCH ACTIVITY (2!L) <br /> r e NORTH _ NEW WELL <br /> MODIF ICATIONlRE PAIR <br /> r _ Deepen <br /> — Olher(Specify) <br /> i s <br /> ' r DESTROY(Describe <br /> Procedures and Materials <br /> ' r Under"GEOLOGIC LOG") <br /> r ° PLANNED USES (2L) <br /> i WATER SUPPLY <br /> Demestic Public <br /> r Irrigation Industrial <br /> w <br /> ' r w MONITORING <br /> e TEST WELL_ <br /> r CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGING <br /> I I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well frons Roarls,Buildings, <br /> Fences,Ricers,etc.and attach a map Use additional paper if OTHER(SPECIFY!) <br /> necessary.PLEASE BE ACCURATE&COAfPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> 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 DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN <br /> (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well'r long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE( FROM SURFACE TYPE <br /> — <br /> DIA. Y z s a MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) GRADE DIAMETER OR WALL IP ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. gm �� (inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> I <br /> i r <br /> r <br /> I r <br /> I <br /> ATTACHMENTS (2L) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned,pertify that this report is complete and accurate to the best of my knowledge and belief. <br /> / n�nil� Y��tln1 (i WM <br /> 1lY�� <br /> — Well Construction Diagram NAMF Oe [ •"r1by�Q V r •-" <br /> (PERSON. FIRM, OR CORPORA DNI (TYPED OR PRINTED) <br /> Geophysical Log(s) ��� �OO �.% `� ��n � / -97� <br /> Soil/Water Chemical Analyses �r �/ YL UG co (� <br /> ADDRESS l /�/� <br /> ATTACH ADDITIONALCITY �y STATE �j J ZIP <br /> Otherb,4 1'•1 INFORMATION, fF!T EXISTS. Signed <br /> W DRILLER/AUTHORIZED EPRESENTATIYE DATE SIGNED C-57 LICENSE NUMBER <br /> DWIR 189 REV- 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />