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i � y <br /> 4}RMINAL STATL OF CAI II,ORNIA DWR USV ONLY — no NOT rr <br /> File t h DWI WELL COMPLETION REPORT <br /> Page Of`_2' Refer to Instrrietlon Pamphlet STATE WELL No/STATION NO <br /> OwneL's Well No 1 / Re t�t►'✓� will N" 7151 O Q <br /> Date 4VGTrk Begiin �j—470 , EnGled "'�� f �11 5? LATITUDE_ ❑ LONOITUDE <br /> LOCIJ Permit Agency .V ✓�+� <br /> Permit No Permit Date D APN1TRsrOTHER <br /> GEOLOGIC LOG t AVE �OWNER <br /> ORIENTATION (✓) X—VERTICAL —HORIZONTAL _ANGLE _,_(SPCCtFn Name JlC <br /> DRILLINGr <br /> Or:PTH FHOM METHOD V FLUID M M"l nAdd"ess _ .�[Z • if <br /> SURFACE DESCRIPTI iv <br /> FL to pL Derarlbe triaterlrtl grain size color, etc Cm' STATE IP <br /> i r � � LYFI. ATIO;V <br /> Address <br /> r rj , <br /> City <br /> _ crJ tU rtJ <br /> county <br /> APN,i Book= Page.}'arce1_ 7,e2 <br /> Townsfup Range 5cetion 12erg, <br /> I <br /> y r latitude DEGMIN SECORTH Longitude oEo i MIN � SEC.WEST <br /> LOCATION SKETCH ACTIVITY (4) <br /> i AlijNORTH _ r ew WELL <br /> 1 ' ` d MODIFICATIONlREPAIR <br /> t I — Deepen <br /> Other(8pucity) <br /> DESTROY <br /> efibo <br /> Procedums and MAron" <br /> tinier GFOLOGrIC too) <br /> t d Lwge ���IC PI.t1i`1N[rD USES f:1 <br /> �• WATER SUPPLY <br /> rtji -7 W �. Do-no-shc �IjC <br /> ' <br /> MONrTORM <br /> "Ja <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> ' MAT EKOHANGiE <br /> 40 DIRECT PUSH <br /> J INJECTION <br /> 1�• s���C"T VAPOR EXTRACTION <br /> r t <br /> SPARG W O <br /> 1 I sour" iiLm;DIATrON <br /> Illrrsirale or Dexribs&Hance of%T1 fro+a Roads Rrrlldtngr <br /> r reaves Rhes etc and attach a map Use arGAI)anal per if OTHER(SPECIFY)-4e <br /> newsary PLEASF BE ACCURATE&COMPLETE (SS 7fjAii� <br /> r r <br /> 1 WATER LEVEL & YIELD OF COMPLETED JYTLLRJ <br /> r DEPTH TO FIRST WATE !(A)6ELOW SURFACE <br /> r , O£PTH OF STATIC / <br /> i = WATER LEVEL i (Fr)t£RATE MEASURED <br /> ESTIMATED YIELD �=t7�—((IPM)&TEST TYPE <br /> TOTAL DEPPtl OF SORENG {Feet) TEST LENGTH airs.)TOTAL DRAWp64JN (FL) <br /> ) <br /> TDTe1i,BhPTFi UI COMPLETED UTLL (Feet) M4y not be representative of a welh long-ret-px yield <br /> DEPTHBORE- DEPTH CASING (S) ►NNt3LAR MATERIALFROM SURFACE HOETW9 <br /> FROM SURFACE <br /> 01A MATERIAL t "MRINIAL GAUGE SLOT SIZE TYPE <br /> R to Ft {inches) GRADE fXAMETER OR WALL. IF ANY MENT TGNITE FILL FILTER PACr( <br /> [fnchag} TFiIfSfJE55 IkidlElsl FL 14 FL (�) (�) (�) (TypElS1ZZW� <br /> r r <br /> of 14116 - <br /> i <br /> Fe <br /> r <br /> 7 <br /> 2.Al 3 p <br /> ATTACHMENTS (4) CERTIF1CArION STATEMENT <br /> Geologic Log 1,the underIned,cerUiy that this sport Is complete and accurate to the hest of my knowledge and belief <br /> _C WeII Construction Diagram NAME Cr!u ►t^/a✓ <br /> IpERSGN RWI,OR C4 BALON) (IYPED Q PRIMED) <br /> — Geophysrl;at Log(s) 1 <br /> — S4ll/Water Chemical Analyses (. <br /> ASS <br /> Other ` CITY STATE zip <br /> ATTACH ADDITIONAL INFORMAT70N iF IT EXISTS [&gned WE ILLER7AU1HCAll EPR WE fiE SIGNED 7iICCN5E hGr ER <br /> D%VR t88 REV Ti v IF ADDITIONAL SPACE 1S NEEDED, USE NEXT CONSECUTIVELY NumeERED FOEIM <br />