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- - -- -- - - - - - - - --- -- - - --- -- --- - ------ -- — <br /> QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I of_L_ Refer !a Instruction FampIdet STATE WELL NO.ISTATION NO. <br /> No.7.62128 ❑ ElOwner's Well No. � - - l <br /> Date Wolk Began m� EadeCl C -r LATITUDE LONGITUDE <br /> :. r <br /> Local Pca-rnit Agency » --�+•�=, <br /> APNITRSIOTHER <br /> Permit No. ' Permit I)ate <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (-t�) VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name V <br /> DRILLING f u 7 c ;r"L} E J I Moat ng Address <br /> u, <br /> DEPTH FROM METHOD b S FLUID - <br /> SURFACE DESCRIPTION — <br /> FL Ic Ft. DrPscrlbe )Naleriat, grant S)_e, color, etc. CITY <br /> WELL <br /> ZIP <br /> y ELL LOCATION <br /> Address 71 <br /> City <br /> I I y rw ixyr i GOltllt}r <br /> APN Boole Page Parcel <br /> Township - Range Section <br /> I I <br /> Latitude ) NORTH Longitude l I I. WEST <br /> DEG. MIN. SEC. DEG. MIN- SEC. <br /> LOCATION SKETCH AC TY (—I ) <br /> I I NORTH EW WELL <br /> MOOIFICATIONlREPAIR <br /> I I V•y 7 { I ', <br /> Deepen <br /> Other(Specify) <br /> AA i <br /> I I 01, } l DESTROY(Describe <br /> r s Procedures and Materials <br /> `;J Under"GEOLOGIC LOG") <br /> ' PLANNED USES (t) <br /> WATER SUPPLY <br /> it 4 <br /> Domestic Public <br /> I � Irrigation Industrial <br /> W l Jco <br /> W } 1 w MONITORING <br /> I TEST WELL— <br /> ( CATHODIC PROTECTION <br /> HEAT EXCHANGE- <br /> - _'� I X DIRECT PUSH <br /> INJECTION <br /> ' VAPOR EXTRACTION <br /> I I ) SPARGING <br /> SOUTH REMEDIATION <br /> tlluahate or Describe.Di.Stnnc'v of Well from Roads,Buildings, <br /> Feure,s,Rii:els,etc.mid a fach r1 Ina 1. Me ndrllttnlxll lllrtper f OTHER(SPECIFY) <br /> nec-evory.PLEASE BE ACCURATE✓?C031PLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER(Ft.) BELOW SURFACE <br /> DEPTH OF STATIC--n "! r/.,. <br /> WATER LEVEL ( (FL)&DATE MEASURED <br /> ESTIMATED YIELD*A ILl (GPM) &TEST TYPE <br /> Y <br /> TOTAL, DETTlf OF BORING 'cr (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN(Ft.) <br /> TOTAL DEPTH OF CO\dPLETED 11'I LL �+ Z+ (Feet) IVlay not be r ep-eselztntive of d well's forte-terYn yield.' <br /> DEPTH CASING (S) OEPTH ANNULAR MATERIAL <br /> FROM SUHFACF BORE-HOLE TYPE FROM SURFACE TYPE <br /> DIA. Y w MATERIAL! INTERNAL GAUGE SLOT SIZE <br /> OF RFN- <br /> (Inches) z ¢ o� GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Fl. to Fl. S o o LL (Inches) THICKNESS (inches) FL to Fl. (�) (TYPE/SIZE) <br /> I 1 <br /> I I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <br /> .�' r } <br /> ell Construction Diagram NAME �' -.� � ''1% ; 4 `` � - ' <br /> (PPr SONO FIRM, OR CORPORATION) (TYPED OR PRINTED) ~ <br /> _ Geophysical Log(s) <br /> // ? 1.1 y t <br /> L Soil/Waler Chemical Analyses r I ` Z r l y u ( — — / 4 `' <br /> ADDRESS 'rf, CITY STATE ZIP <br /> •L Other _... t�•-- ' '`� '-1 _ -,--t -� la7 . <br /> ATTACH ADDITIONAL INFORMATION, 1F 1T EXISTS. Signed <br /> WELL DRILLEOWITTHORtED REPRE15TATIVE DAT SIGNED - NUMBER <br /> D\+'u MS KFW. a-!) IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM P <br />