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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page <br /> P of ( '+ ITef— to Instrar,0011 pamphlet STATE WELL NO-!STATION NO. <br /> ❑ ❑ <br /> wner's �"°.12141 <br /> OWell No. <br /> � <br /> �'- - LATITUDE LONGITUDE <br /> Date)York Began �- Ended ' <br /> = Local Permit Agency, <br /> - � _ APNITRSlOTHER <br /> Permit No. 1 Permit Date } ' <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (2L) VERTICAL HORIZQNTAL —ANGLE _(SPECIFY) Naim Er - <br /> DRILLING <br /> METHOD '� k �t FLUID Mallin Adch-ess <br /> DEPTH FROM DESCRIPTION � `" <br /> SURFACE <br /> F1. la Ft_ Describe material, grain si;ze, CU{Or, etc. CITY STATE ZIP <br /> EJ.L L�ATIQN <br /> I I <br /> Address 4 r W <br /> City— <br /> county <br /> ity COL1ty <br /> APN Book Page Parcel <br /> I I To%vuship - Range Section <br /> I I Latitude' 1 1 '" 1 NORTH LOrigitudO l' I ._ .' I ~'- WEST <br /> DEG- MIN. SEC. DEG- MIN. SEC. <br /> LOCATION SKETCHACTIVITY (�) <br /> I I NORTH _ NFW WELL <br /> t.A MODIFICATIONIREPAIR <br /> Deepen <br /> I I ' <br /> ..'Y—"'-"e'� •{ — Olher(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> PLANNED USES i <br /> WATER SUPPLY <br /> Domestic Public <br /> I T Irrigalion Industrial <br /> I I LU w MONITORING . <br /> I I TEST WELL <br /> I I CATHODIC PROTECTION <br /> `` HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> I VAPOR EXTRACTION <br /> I I SPARGING <br /> SOUTH REMEDIATION <br /> IUustrale or Describe Distance of We {mn Roads,Buildings, <br /> I I Fences,Ricers,c?a tint!attach a ma I.C1se addition ' <br /> al aper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURWE COMFLET . <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC� _. <br /> I I WATER LEVEL (Ft.)&DATE MEASURED <br /> 4r 1 <br /> I <br /> ESTIMATED YIELD ''Ii (GPM) &TEST TYPE <br /> TOTAL DA:P"I`LI OF BORING .i / (Feet) TEST LENGTH�')1 ' (His.)TOTAL DRAWDOWN <br /> TOTAL DEPTH OF COMPLETED WIsI..t., (fnet) `May not be representative of a well's long-tcl7r7 yield. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE_ <br /> FROM SURFACE HOLE TYPED FROM SURFACE TYPE <br /> i r z , a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE- i <br /> D FILTER PACK <br /> (Inches) Z w zF a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Fl. to Fl. g v �� (inches) THICKNESS (Inches) Fl. to Ft. (TYPEISIZE) <br /> ry/ tet# '.: i L:> <br /> I I t <br /> I I <br /> I I <br /> A ;TACHMENTS CERTIFICATION STATEMENT <br /> I, the undersigned, certify that this report is complete and accurate to the est of my knowledge and belief. <br /> Geologic Log <br /> ell Construction Diagram NAME <br /> (PERSON, FIRM OR CORPORATION) (TYPED OR PRINTED) _ <br /> Coophysical Logs} <br /> -f � d - i-�-•' - _� � - f" ,.. ,� r_' _ � fes!_ ,:.'� �, {� ! i _ <br /> _ oil/Waler,Chernic 16nalyses"' <br /> - ? l ADDRESS I , CITY 1 STATE -_ y ZIP <br /> Olher <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL ILLER/AUT ORIZEO REPRESENTATIVE GATE 516NE0 Z-O LICENSE NUMBER <br /> DWI! 155 REN, II-D IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />