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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page 1 of 1 Refer to Instruction Pawphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well No. �'` 1=r0- <br /> /�3]0 0 <br /> Date k'`/Dile Began 1, !,,Ended t - - LATITUDE LONGITUDE <br /> Local Permit Agency r �` <br /> I _ i APNITRSIOTHER <br /> Permit No. - s_'• Permit Date <br /> �//GEOLOGIC LOG , ` WELL OWNER <br /> ORIENTATION (�) '�VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) NaTlle -r L.— �`-'_ 'I'( <br /> DRILLING { lVllil7n Address J � ' -' LT <br /> DEPTH FROM METHOD = r FLUID ' ,meg <br /> SURFACE DESCRIPTION 7 f <br /> Fl. to FL De.scrilm material, grain .Size, color, etr. CITY <br /> WELL <br /> ZtP <br /> ELL LOCATION <br /> Address r I s <br /> I I city <br /> County — <br /> APN Book Page Parcel <br /> Township_-- Range—section <br /> Latitude "' I �'I NORTH I WEST <br /> i I I'y <br /> DEG. MIN. SEG. Longihule DEG, MIN. SEC. <br /> LOCATION SKETCH A TY (�} <br /> NORTH ✓ <br /> NEW WELL <br /> L;IJ MODIFICATIONIREPAIR <br /> Deepen <br /> 1 <br /> Other(Specily) <br /> f <br /> I I <br /> DESTROY(Describe <br /> 4 ` Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> ` ? PLANNED USESO <br /> I I ` WATER SUPPLY <br /> I _ Domestic _ Public <br /> Irrigation — induslrial <br /> w - �. n <br /> - --- - - i w MONITORING <br /> RTEST WELL <br /> CATHODIC PROTECTION <br /> l i i I HEAT EXCHANGE <br /> - DIRECT PUSH <br /> INJECTION <br /> I I <br /> VAPOR EXTRACTION <br /> SPARGING <br /> i SOUTH REMEDIATION <br /> 111ushnle m-Describe Uislance of lVell from Roark,Buildings, <br /> 1,ences,dices,e(c-and allach a mr, se additional roper if OTHER(SPECIFY) <br /> uecessaty.PlEASE BE ACCURATE !v C0,11PLET,. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER - (FL) BELOW SURFACE <br /> DFPTH OF STATIC <br /> I WATER LEVEL r 7 (FL)&DATE MEASURED - <br /> I I <br /> ESTIMATED YIELD ' = (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BONING - (beet) TEST LENGTH 1. (Firs.) TOTAL DRAWDOWN S(FL) <br /> TOTAL DEPTII OF COMPLETED NVELL (FeeO *Allay not be represelttative of a well's 1077g-ter-711 yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE(—} FROM SURFACE TYPE <br /> _. DIA. Y w ¢o Q MATERIAL I INTERNAL GAUGE SLOT SIZE USEN{Inches) oza GRADE DIAMETER OR WALL IF ANY �CE_ <br /> NTILL FILTER PACK <br /> FI. to Ft. m o (Inches) THICKNESS (Inches) Fl. to FL �) �) (TYPE/SIZE) <br /> I 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 Lag <br /> well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> _ Geophysical Log(s) s <br /> ` __�SoilMlater Chemical Analyses <br /> ' then ADDRESS ! CITYr 1 STATE - ZIP <br /> O <br /> ATTACH ADDITIONAL INFORMATION, 1F IT EXISTS. Signed r/ <br /> WELL UMLLER/AfitHORIZED REPRESENTATIVE 74 DATE IGNED _ L47 LICENSE NUMBER <br /> OMB LSN RCT. 11,07 IF ADDITIONAL SPACE IS NEE ED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />