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QUADRUPLICATE STATE OF CALIFORNIA I USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page�__of_L_ Refer to Instruction PnurpIllei STATE WELL NO.ISTATION NO. <br /> Owner's Well No. 1It filo.'}��i l�C LlLl <br /> Date VAlorlc Began ���-:���, Endedr (`v LATITUDE LONGITUDE <br /> Local 1'crmit Agency' ,� y y h <br /> APNITRS/OTHER <br /> Permit No. r I Permit Date <br /> GEOLOGIC LOG _ WELL (OWNER <br /> ORIENTATION (✓) 1--<ERTICAL —HORIZONTAL —ANGLE —SPECIFY) Name-L ',3 <br /> DRILLING - Mailing Address <br /> ❑EPTH FROM METHOD::S -•i �T._ h FLUID g <br /> SURFACE DESCRIPTION <br /> Ft. to FlDescribe malerial, grain YiLc, color, Etc. CITY STATE ZIP <br /> WELL Address -7LOCATION <br /> � -- - <br /> -17 <br /> r <br /> A,PN Book Page Parcel <br /> Township Range Section -` <br /> I x <br /> Latitude.'... __ I I i € NORTH LOngltnde' .- I f-� WEST <br /> DEG. _Mll. SEC. OEG. MIN. SEC. <br /> LOCATION SKETCII ATIVITY (�) <br /> I I NORTH NEW WELL <br /> ?,_I MOOIFiCATIONlREPAIR <br /> j _ Deepen <br /> Other(Specify) <br /> I I - <br /> DESTROY(Describe <br /> \ r Procedures and Materials <br /> I I I Under"GEOLOGIC LOG"J <br /> PLANNED USES (2:L) <br /> WATER SUPPLY <br /> Domestic Public <br /> I I --1! Irrigation Industrial <br /> I ` ¢ MONITORING Z <br /> w <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> I I <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> 111milate or-Describe Diomic•e of Nell fon)Roads,Buildings, <br /> Fcucrs,8icels,etcr mtd rrttrrch n,uap, bse additimrnlpnper if OTHER(SPECIFY)— <br /> ucreaxary.PLEASE RE ACCURATE�*C011iPLET''. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER' BELOW SURFACE <br /> I I i <br /> DEPTH OF STATIC rf j <br /> I I WATER LEVEL r (Ft.)&DATE MEASURED c 1ti <br /> I I ESTIMATED YIELD (GPM) &TEST TYPEti <br /> TOTAL DEPTH OF BORING +4 {Feet) TEST LENGTH ! (Hrs.}TOTAL DRAWDOW :fV�f r=im{Ft.) <br /> TOTAL DEPTH OF COMPLETED 11TELE Y (Feet) 2vIaj,not br representative of a well's long-regia Meld. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE(-) FROM SURFACE TYPE <br /> DIA. Y Iz o¢ MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE- BEN. FILTER PACK <br /> pnches) a w o GRADE DIAMETER OR WALL IF ANY lTONITE FILL <br /> z z <br /> FL to Ft. m v of (Inches) THICKNESS (Inches) Ft. to FL (TYPE/SIZE) <br /> Ar <br /> 77 <br /> II I <br /> ATTACIBIENTS CERTIFICATION STATEMENT <br /> I, the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> iGeologic Log <br /> ellwell Construction Diagram NAME '" �i`r 1 t <br /> --" (P , FIRM,tlOR CORPORATION) (TYPED OR PRINTED) _ <br /> Geophysical Log(s) <br /> _,e'Sa UWater Chemical Analyses <br /> AJ� <br /> ADDRESS CITY STATE -� ZIP <br /> ATTACH ADDITIONAL-INFORMATION, 1F IT EXISTS. Signed ` A <br /> WE RILL 1AIITHORIZED REPRESENTATIV _ DAT SICNED NIll <br /> Dust Tis 31 11-97 IF ADDITIONAL SPACE ISN EDED, USE NEXT CONSECUTIVELY NUMBERED FORM �,I": <br />