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QUADRUPLICATE STATI; OR CALTFORNIA DWR USE ONLY DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page i Of f Refer to Tn Slrucfion Painpllfet STATE WELL NO.ISTATION NO. <br /> 0,wner's Well No. No <br /> Date 117ork Began- <br /> e 1 tel', E1Tded r �62131 LATITUDE LONGITUDE <br /> r <br /> Local Permit Agency <br /> APNITRSPOTHER <br /> Pori-nit No. i - Permit Date - <br /> / GEOLOGIC LOG _ WELL OWNER <br /> ORIENTATION (!) Y VERTICAL HORIZONTAL ANGLE —(SPECIFY) NalnP, h <br /> DRILLING MailingAddress - - <br /> DEPTH FROM METHOD FLUID <br /> SURFACE DESCRIPTION ; <br /> FI. 10 Ft. Describe inaterial, grain size, color, efe. CITY STATE ZIP <br /> WELL LOCATION, <br /> Address <br /> /city <br /> I �_ LT ^\ t 1 _ County <br /> APN Book Page Parcel <br /> .. ) Township Range Section <br /> Latitude–L-l. I" --i ' •.NORTH LOng]tlldl',` � I . 'r.I "-"'WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY I} <br /> I I NORTH o�NEW WELL <br /> MODIFICATION/REPAIR <br /> I I -.-_I Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> �� lJ Procedures and Materials <br /> I I - r -4 - Under"GEOLOGIC LOG") <br /> I I _ PLANNED USES (t) <br /> WATER SUPPLY <br /> Domestic _ Public <br /> I Irrigation Industrial <br /> I ¢ MONITORING ' <br /> w <br /> I - TEST WELL <br /> I I 1 CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> I I <br /> -- INJECTION <br /> I I VAPOR EXTRACTION <br /> I I SPARGING <br /> SOUTH REMEDIATION <br /> I <br /> 7lhlshvafe orDescli6e Distance of Well fronl Roads,Buildings, <br /> I I Fences,13icers,etc.and allach a mop Uve additional paper f OTHER(SPECIFY)— <br /> necessan�.PLEASE BE ACCURA E&COMPLET . <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I � <br /> DEPTH TO FIRST WATER e — (FI.) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC - l - <br /> WATER LEVEL (F1.)&DATE MEASURED <br /> I ESTIMATED YIELD.' t ( � (GPM) &TEST TYPE - - 1• <br /> "NOTAL DEPTH OF BORING (Feet) TEST LENGTH ., I s. (Hrs.)TOTAL DRAWDOWN �j (Ft.) <br /> TOTAL DEPTH OF C0l1IPLCT[,D 11 ELL r r (Feet) *]Vlay not be representative of a well's long-term yield. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DFPTH BORE- <br /> FROM SURFACE HOLE TYPE{—} FROM SURFACE TYPE <br /> DIA. Y z o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- FILTER PACK <br /> (Inches) oU J GRADE DIAMETER OR WALL IF ANY Ft. la Ft. MENT TONITE FILL (TYPEISIZE) <br /> Fl. Io FI. m a o� (Inches) THICKNESS (Inches) <br /> I I <br /> I I <br /> I l <br /> ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> I,the undersigned, ce}lify that this report is complete and accurate to the best of my knowledge and belief. <br /> �eologic Log <br /> Well Construction Diagram NAME <br /> - . (PERSON, rIRW, 01( CORPORATION) (TYPED OR PRINTED) <br /> ophysical Logs) M - <br /> SoillWaler Chemical Analyses ! ! _ <br /> ADDRESS CITY STATE ZIP <br /> Other 1 b <br /> Signed <br /> I <br /> ATTACH A0DITf0NA1 1NF0RMATl0N, IF 1T EXISTS. Si A WELL D ILLERjiUTHORIZEO REPRESENTATIVE,' DATE GNEO LICENSE NUMBER <br /> DWR 198 IIEV, 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />