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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT F1111111111 I <br /> Page_of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. I I I 1 ❑1 1 1 1 1 119 ❑ <br /> LATITUDE LONGITUDE <br /> Date Work Began � ' Ended ` <br /> Local Pen-nit Agency APN/TRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG �tWCE!LL O� ERS( -yq—+}(/ <br /> ORIENTATION (= ) Y VERTICAL —HORIZONTAL —ANGLE _(SPECIFIC Nat ne �a lot `✓ovi [c'' `�-�'"� -- <br /> ILLING rAtq) <br /> DEPTH FROM <br /> METH -lingFLUID, �� 1 Mailing Address <br /> SURFACE DESCRIP ION <br /> Ft. to Ft. DCSCrihe material,gretin .Size, color, etc. CITY STATE ZIP <br /> J , Address FELL LOCATION <br /> City <br /> �� Vu County <br /> Z APN Book Page Parcel <br /> col+ ' r \Nr_� CkAw Township Range Section <br /> tL 1 ZZ rs ZAVL-L, Latitude I I NORTH Longitude I I WEST <br /> $ DEG. MIN. SEC. DEG. MIN. SEC. <br /> t LOCATION SKETCH A VITY (2�) <br /> 5 ' 1 2_ N TH NEW WELL <br /> _ MODIFICATION/REPAIR <br /> t r°�AT�Y 1 s L 4.�°rGS /• — Deepen <br /> ' l i2t) I� Other(Specify) <br /> V Y s — DESTROY(Describe <br /> Procedures and <br /> Q I i Under"GEOLOGICMaterials LOG") <br /> ,,t / PLANNED USES 0!) <br /> a7 1 i yIJ'd s ? Y WATER SUPPLY <br /> _ 0 , _ Domestic P Ile <br /> L/ Irrigation Industrial <br /> I I W a MONITORING <br /> � W <br /> I I TEST WELL_ <br /> i CATHODIC PROTECTION_ <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> _oINJECTION_ <br /> ('--I VAPOR EXTRACTION_ <br /> SPARGING_ <br /> r _ — O REMEDIATION <br /> Iffivornte or Describe Distance of iVe ll f(vin Rands.Buildin; <br /> Fences.Riuns,etc.and aw,ch a nurtl.I'se addifitnull t'niur if OTHER(SPECIFY)_ <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> I DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED ^� <br /> ESTIMATED YIELD'—LL(GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING Fez4 TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED "ELL 'D (Feet) "May not be representative of a well's long-teen yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE('') FROM SURFACE TYPE <br /> DIA. Y z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE. SEN- <br /> (Inches) -.- z- a GRADE DIAMETER OR WALL IF ANY MENT TONRE FILL FILTER PACK <br /> Ft. to Ft. oQ (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> s ( :�) (�) <br /> C) 4X 7� 21 t v 22 k •Yo Lk14P=� <br /> 20 s x s sit O ;2_0 <br /> 1c <br /> I 1 <br /> I <br /> ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that thi report Is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log p 1 t, � j� <br /> _ Well Construction Diagram NAME T f 1D4W I�I`"—, <br /> Geophysical Log(s) (PERS FIRM, OR FO ORATION) PPED OR PRIMED) <br /> _ <br /> _ SoilWater Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> _ Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C•57 LICENSE NUMBER <br /> MVP IBL• acs: I,o- I= AnnITInAIAI CPA!`= IC kl==n=n I IC= Mr-VT f.nKICP1'I ITn/=I V All RAPPO=n =naeA <br />