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ORIGINAL � /—_-' <br /> - Nr- —�� _7 STATE OF CALIFORNIA F - DWR USE ONLY — DO NOT FILL IN <br /> File with DWR ;\ ` LL COMPLETION REPORT <br /> I <br /> Page ` of �� u Li Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well No, z . 729918G <br /> Date Work Began 1 4—OD Ended 7 1 —o LATITUDE LONGITUDE <br /> Local Permit Agenc _iSJ Pl .s <br /> Permit No. b v� 3Q `�� Permit Date 9 1Z.-O " <br /> PN/TRS/OTHER <br /> GEOLOGIC LOG [QWELL OWNER / <br /> ORIENTATION (.!:L) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name u 1 V 5ev V 1`� L/_L C <br /> DRILLING Mailing Address <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE DESCRIPTION BurbQh LL C Tip <br /> Ft, to FL Describe material, grain size, color, etc. CITY STATE ZIP <br /> L LOCATI N <br /> Address 0 <br /> City. <br /> G <br /> I I <br /> CountyOL7914M <br /> ' APN Book Page Parcel <br /> Township Range A�_45t Section <br /> Latitude_-_ I I NORTH Longitude IWEST <br /> I DEG. MIN, SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> ' I NORTH NEW WELL <br /> I <br /> MODIFICATIONIREPAIR <br /> I Irn tkT. _ Deepen <br /> _ Other{Specify) <br /> : t <br /> DESTROY(tlescrtbo <br /> r r Procedures and Matenats <br /> Under"GE=OLOGIC LOG') <br /> PLANNED USES (�} <br /> WATER SUPPLY <br /> I 1 <br /> — Domestic Public <br /> F _ trrigation Industrial <br /> WMONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> r t HEAT EXCHANGE <br /> F t <br /> DIRECT PUSH <br /> INJECTION <br /> F 4 <br /> VAPOR EXTRACTION <br /> I r SPARGING <br /> SOUTH <br /> Iilrrsfmte or Describe Distance of 1VeR ffrrnm Rorrrfs,Brerlrling5, REMEDIATION <br /> F I Fences,Rivers,etc.and attach a clay. Me additional pnper if OTHER(SPECIFY) <br /> necessartf.PLEASE BE ACCURATE&COMPLETE. <br /> ' WATER LEVEL & YIELD OF COMPLETED WELL <br /> F I <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I 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 /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE_ FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(�) <br /> DIA. x w ¢o a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE- BE S ¢ �� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. (Inches) THICKNESS (Inches) Ft. to FL (TYPE/SIZE) <br /> "� LL cam) <br /> I <br /> I <br /> 1 <br /> I I <br /> I 1 <br /> t ATTACHMENTS (.!:L) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> GeLag _yv,y a y -Cf�ya e1q �n l inj �I <br /> We!!ll Construction Diagram NAME , <br /> Geophysical Log(s) (PERSON, {IRM, OR CORPOR ON) (TYPED OR PRINTED) <br /> Soil/Water Chemical Analyses R70 Dekkf �� ialVW <br /> "[ b <br /> Other <br /> ADDRESS //�- J�le ` CTry @_ A STATE�Q ZIIPPP <br /> ATTACH ADDITIONAL INFORMATION, 1F IT EXISTS. Signed Y'" k`zl'x DL(�� �~D —✓ <br /> HQERILLER/AUTHDRI!P REPRESENTATIVE v DATE SIGNED C57 LICENSE NUMBER <br /> DV7R 188 DEN•. a-s. IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />