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<br /> QUADRUPLICATE t STATE OF CALIFORNIA �I
<br /> r For Local Rqulrements Syi f_WELL COMPLETION REPORT
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<br /> STATE WELL NO ISTATION NO s
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<br /> Owner's Well No t }'`r�i" U� 70 V 19 r t
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<br /> s~r LATITUDE LONGITUDE
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<br /> CEOLOCIC LOG Jh J `VELL O`VNFR
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<br /> T ORIENTATION (�) F�VERTICAL _HORIZONTAL ANGLE'_(SPECIFY) NanlC `f' w i'^ -° --
<br /> DRILLING 1i.U4}141 ' r sieiP,r+ry �� f )�}1j r�f�`."� p,}'�sw� ° }
<br /> METHOD I fi FLUID LI Addretis j c f� _
<br /> DEPTH FROM v E sk,�q•����t:t�, "�w ` a ` 14! �� I-,5
<br />' SURFACE DES(RIPTION - I n "
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<br /> Ft to Ft h t �\ -.�� `^`S✓" \ \, \ t„d
<br /> WELL LOCATION
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<br />`I MODIFICATIONlREPAIR '� 14,
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<br /> Other(Specify) s !
<br /> DESTROY(Describe { N it
<br /> Procedures and Materrats
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<br /> Uner GEOLOGIC LOG
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<br /> it I FI t r1(i ,,�•� J f„Ji , n ' L
<br /> PLANNED USES{(�) to
<br /> WATER SUPPLY i
<br /> Domestic Public
<br /> Irrigation Industrial
<br /> w ' MONITORING a,
<br /> TEST WELL k
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<br /> I I - CATHODIC"PROTECTION
<br /> HEAT EXCHANGE
<br /> DIRECT,PUSH ! ii
<br /> INJECTION
<br /> 4 3[ VAPOR EXTRACTION_ )
<br /> I I r ` ' "�,. yfl>"� .''4 #lJ ""4 4 SPARGING 1
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<br /> ' I I SOUTH REMEDIATION "
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<br /> n(cessrrr7f PI EASE RE ACCURATE&COAIPI1,TF
<br /> NATER LEVE & ]IELI? OT COMPLETED NL'I,LL +'
<br /> DEPTH TO FIRST WATER -� (Ft) BELOW SURFACE
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<br /> DEPTH OF STATIC y 4 11 Z - .
<br />' WATER LEVEL (Ft)d DATE MEASURED `
<br /> ESTIMATED YIELD (GPM) & TEST TYPE
<br /> C TOTAL DLPTII OE B0131INC TEST LENGTH '(Hrs)TOTAL DRAWDOWN^ (Ft) `{
<br /> �r [ TOTAL DE,PTII OF COMPLETED WELL "� a (kc�t) *Nlrry Iaothe�epleses7trteve of rf cell's long-tcn�n yrc(d r � ap�
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<br /> DEPTH BORE t ,CASIhC 5 DEPTH A711ULA$ '1IATERIAL.r� ;j
<br /> FROM SURFACE HOLE TYPE(—') FROM SURFACE TYPE
<br /> I± DIA r w O a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN I I
<br /> " e (Inches) S 0 i, J GRADE DIAMETER OR WALL IF ANY 'v MENT TONITE FILL FILTER PACK t
<br />'I ) Ft to Ft m ca o (Inches) THICKNESS " (Inches) A to Ft (TYPEISIZE)
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<br /> " /ATTACFIMENTS (�) CERTIIICATION STATEMENT y�
<br /> f° I the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief j
<br /> yy Geologic Log d r 1 e
<br /> r'� s,'`/Y 4r ✓. ✓r ywr .., Y t 'Se
<br /> 3 Well Construction Diagram NAME `•`
<br /> 1 F� (PERSON FIRM OR CORPORATION)r (TYPED OR PRINTED) ' )
<br /> GeophyslcW Log(s)
<br /> G J , e ,P '.
<br /> Sotl/Water Chemical Analyses, 0
<br /> Iti"' 1F ADDRESS CITY STATE ZIPOther "i
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<br /> 6 ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed i•"f �� ""3P^ ,`'^� ��r �` �'t `f
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<br /> WELL DRILLERIAUTHORIZED REPRESENTATIVE �'�.:...�� DATE'SIGNED F57 LICENSE NUMNER 2
<br /> i " i I)%1Ij I" GF1 II 9T ,IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM ' r=
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