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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 a l Hefe+ to Pnstrrirtion Pamphlet STATE WELL NO.lSTATION NO. <br /> Om mer's Well No. Mk A � � No. <br /> i� <br /> Date Work Began �!'_ '� Encl�ed =�'� � <br /> ?.�I Local Perinit Agency. <br /> .- <br /> APNITRSIOTHER <br /> Ph'7Hllif No. - I ` Permit Date <br /> GEOLOGIC LOG ,WELL OWNER <br /> ORIENTATION (2L) VERTICAL HORIZONTAL —ANGLE (SPECIFY) Name <br /> DRILLING .r r�I, ^, — L R :+r <br /> DFROM METHOD -� 1 FLUID �1( `' NlailiT�ddress <br /> EPTH � - r� <br /> SURFACE DESCRIPTION ' ° 'a - <br /> Ft. Io FI. Describe material, grain slime, Color, etc CITY STATE ZIP <br /> WELL hOCATWN <br /> Address <br /> t COUn <br /> -- APN Book Page Parcel <br /> To4euship�_ I3an�e Section T <br /> Latitude -. I.� ,- I-� �.: NORrH Longitude) .� s' I. I ? wesT <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH 71TY, (:) <br /> I I NORTH , NEW WELL <br /> MODIFICATION/REPAIR <br /> i I t ` _ Deepen <br /> _ Other(Specify) <br /> I I <br /> DESTROY(Describe <br /> Procedures and Malenals <br /> €` Under"GEOLOCIC LOG') <br /> r PLANNED USES (_v) <br /> WATER SUPPLY <br /> Z_ Dameslic Public <br /> I I ,...�_....^-.._..._ '. ....1 i - Irrigation Industrial <br /> H _ . <br /> Luf a MONITORING <br /> 3 w <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> - - - i HEAT EXCHANGE <br /> I I <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGING <br /> SOUTH REMEDIATION <br /> Idlustr-ate w-Describe Distance of Well_fronf Roark,Boiidings, <br /> Fences,Ricers,etc.and enact a mrp Use additional 7gaper if OTHER(SPECIFY) <br /> necessary.PL FA,SE BE ACCURATE&CprTfPLETE. <br /> I I <br /> WATER LCV.�L MELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO RBST WATER (Ft.) BELOW SURFACE <br /> i DEPTH OF STATIQ,� <br /> WATER LEVEL (FI)&DATE MEASURED ' <br /> _ ESTIMATED YIELD ' 4't 1 '� (GPM)&TEST TYPE r-T <br /> TOTAL DEPTH OF BORING s (Feet) _ TEST LENGTH '�^1" (Hrs.)TOTAL DRAWDOWN �r (FL) <br /> TOTAL DEPTH OF (DMPLETED 11TLL (Feet) I "Inlay not be representative of a well's long-tei-m yield, <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE TYPE_( } FROM SURFACE TYPE <br /> DIA. Y z a MATERIAL! INTERNAL GAUGE SLOT SIZE CE-7BE{Inches) a '-" z� rz GLADE DIAMETER OR WALL IF ANY MENILL FILTER PACK <br /> Fl. to Fl. Jm �� (Inches) THICKNESS (Inches) FL to Ft. (TYPF/SIZF) <br /> I I <br /> I I <br /> I I <br /> ATTACHMENTS (�L) 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 j +_ <br /> Well Construction Diagram NAME - <br /> - {PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) / y <br /> •f SoillWaler..Chemical Anal - <br /> } '.ra -Other ADDRESS ! CITY STATE ZIP <br /> � I - - �- e�.., ,. � -; L `� •:.'-� <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS Signed <br /> WELL D ILLERlADT ORIZED REPRESENTATIVE DAT SIGNED LICENSE NUMRER ..� <br /> DR'IT TNR RFV. lI-p; IF ADDITIONAL SPACE IS NEEDLD, USE NEXT CONSECUTIVELY NUMBERED FORM <br />