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TRIPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> Owner's Copy WELL COMPLETION REPORT <br /> Refer to In.straction Pamphlet STATE WELL NO/STATION NO. <br /> Page of ❑ ❑ <br /> Owner's Well No. ..� <br /> Date XVork Began nded o 9 0 5 1 11 LATITUDE LONGITUDE <br /> Local Permit A encu <br /> p APN/TRS/OTHER <br /> Permit No. 4h j 4., Permit Date :`4) !! <br /> GEOLOGIC LOG ( L OWNER <br /> ORIENTATION (2!L) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Na. Wilk,.` h`'' �'� c <br /> DRILLING <br /> DEPTH FROM METHOD FLUID Mailing Address <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. De.'cribe inaterial, grain size, cOlOr, etc. CITY STATE ZIP <br /> 4 Address? WELL LO TON <br /> I _ <br /> City <br /> County a.l" 0! <br /> LI <br /> APN Book Page Parcel <br /> +: Township Range Section <br /> Latitude t t NORTH Longitude WEST <br /> DEG. MIN, SEC. DEG. IN. SEC. <br /> t LOCATION SKETCH TIVITY <br /> - NORTH NEW WELL <br /> ' MODIFICATION/REPAIR <br /> — Deepen <br /> — Other(Specify) <br /> I i <br /> I I� <br /> fir. 7� DESTROY(Describe <br /> Procedures and Materials <br /> - f � � Under"GEOLOGIC LOG' <br /> ^ PL ED USES (�) <br /> J-37i(,�_ a ER SJPPLY <br /> _ Do tic Public <br /> Irrigation Industrial <br /> [n ~ <br /> - 1 W MO. <br /> ~' C L.A. j � - TEST WELL_ <br /> (U\ <br /> C7�tHO PROTECTION <br /> HE I HEAT EXCHANGE <br /> I <br /> DIRECT PUSH_ <br /> ` INJECTION_ <br /> VAPOR EXTRACTION_ <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Ilhrstrrur or Describe Distance of FVell(ruin Roa ls,Buildings, <br /> Fences,Ricers,etc.and attach d map Use additional pnI if OTHER(SPECIFY)_ <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> r .f L <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC O) <br /> WATER LEVEL (Ft.)8 DATE MEASURED <br /> r <br /> ESTIMATED YIELD �� (GPM)to TEST TYPF ) <br /> TOTAL DEPTH OF BORING ( et) TEST LENGTH!Z-- (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL. DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE(-) FROM SURFACE TYPE <br /> DIA. >< z ¢ aMATERIAL/ INTERNAL GAUGE SLOT SIZE CE <br /> • BEN- <br /> pnchesl = w z 0� a FILTER PACK <br /> Ft to Ft 5 o � GRADE DIAMETER OR WALL IF ANY Ft to Ft ME ONITE FILL (TYPE/SIZE) <br /> m N o LL (Inches) THICKNESS (Inches) <br /> _. <br /> i I <br /> I v i <br /> I <br /> i I <br /> ATTACHMENTS ( ) CERTIFICATION STATEMENT <br /> Geologic log <br /> I, the unde signed, ce that this re Is complete and accurate to the best of my knowledge and belief. <br /> f _ <br /> ._ Well Construction.Diagram NAME / � A ''-+4 <br /> (PERS FIRM, OR CORPORATION) (TYPED OR PRINT D) •ti <br /> Geophysical Log(s) {/✓�� ►/g� (/ <br /> Soil/Water Chemical Analyses I �" I ( L l <br /> Other <br /> ADDRESS ��• CITY STATE ZIP <br /> �•r �, � "j�] <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. "'WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> l�,"R Itis REV n-gs IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />