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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page i of 1 Refer to lnsrrncrinul]Panphler STATE WELL NO.ISTATION NO. <br /> Owliei's Well No. <br /> Imo'V '�I '�/ -- No.7 L 2 ❑ ❑ <br /> ! •� - f- LATITUDE LONGITUDE <br /> Date S,1Torl< Began�-3 1 `, Ended — ,I <br /> Local Permit Agency <br /> . APNITRSIOTHER <br /> Permit No. Permit Date <br /> �// GEOLOGIC LOG ff` ALL OWNER <br /> ORIENTATION (`�} =VERTICAL —HORIZONTAL ANGLE —(SPECIFY) Narne <br /> DRILLING -` <br /> METHOD .!;,A FLUID 1 ll S Nailintress <br /> DEPTH <br /> }sRACEE DESCRIPTION <br /> - <br /> _ <br /> FL to Ft. DescOhe material, grain Sipe, color, etc. CITY ! IOC STATE ZIP <br /> WELL .00t? �. <br /> Address ' <br /> I I <br /> cit), <br /> I I �'� �� ./� •._—?- e Counter .� -_' --,t ,;,r—;-- _2 .r'�� <br /> APN Book Page Parcel / <br /> Torrmship Range Section - <br /> I I LatiLude, �.--rA" i NORTH Longitudd i I" t � WEST <br /> DEG. MIN. SEC. DEG. MIN, SEC. <br /> LOCATION SKETCH AIVITY (�) <br /> I I NORTH <br /> NEW WELL <br /> MODIFICATIONIREPAIR <br /> _ Deeper <br /> '• _ Other(Specily) <br /> S <br /> DESTROY{Describe <br /> ,-- --- Procedures and Malenals <br /> qlz`4 Under"GEOLOGIC LOG') <br /> PLANNED USES (.i:�) <br /> i <br /> A. - e WATER SUPPLY <br /> Domestic Public <br /> u] <br /> Irrigation Industrial <br /> w r w MONITORING ` <br /> 1 <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> '• HEAT EXCHANGE <br /> _T DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I I SPARGING <br /> i SOUTH REMEDIATION <br /> Illushxrte or Describe Distance of Well linin floods,Buildings, <br /> fences,Rirraa,&c.mtd attach a Inap Ilse additioual paper if OTHER(SPECIFY) <br /> necesvard.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIE.LD OF COMPLETED WELL <br /> I I <br /> I DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC�f I <br /> I I WATER LEVEL f �(FL)&DATE MEASURED <br /> I q ESTIMATED YIELD ' ?{ t� (GPM) &TEST TYPF. <br /> 1 <br /> TOTAL DEPTH Ole BORING '� '� (Feet) TEST LENGTH"-� (Hrs.)TOTAL DRAWDOWNT(Fl.) <br /> TOTAL DEPTH OF CO1,fl'L r',LTD IItELL �� (Feet) *1Vfay not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE(} FROM SURFACE TYPE <br /> HOLE <br /> DIA. Y z a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- FTONIT)r <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MENTFILL FILTER PACK <br /> Fl, to Fl. m of (Inches) THICKNESS (Inches) FL to FL (TYPElSIZE) <br /> I <br /> I I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log <br /> I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME <br /> (PL SDN, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> eophy5ical Logs) <br /> _ SoillWaler Chemical AiraPMS 1 11 <br /> ADDRESS w,. •� CITY _- STAT r ZIP } <br /> Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed WELL DRI RlAUTHO ZED REPRESENTATIVE DATIt sic `^I NUMBER <br /> DWR 168 ItLN'. II-q; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM - <br />