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I <br /> QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page—oft Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. MW-3 No. 0989450 <br /> Date Work Began U i{:1 14 r Ended (t113115 LATITUDE LONGITUDE <br /> Local Permit Agency N j:0 A C+�i I Fr1 t U Al j t'1 I I I 1 1 1 1 1 1 <br /> Permit No. to 00:3:j!6'7_4. Permit Date 10 (� APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name_ S T U C a- <br /> DRILLING rr- Mailing Address ti V U Fz P o r W A <br /> DEPTH FROM METHOD H S A V G 1_. � FLUID_NON N� g 0 -' f�Y <br /> SURFACE DESCRIPTION 5 T:6 C k T o ('1. S ZS? (1 <br /> Ft. to Ft. Describe material, grain size, Color, etc. CITY STATE ZIP <br /> I WELL LOCATION <br /> Address :j A©Q S C b ALN ;T_ <br /> City <br /> County C _h N T U Q V I N <br /> APN Book?I Page 'I G n_Parcel?s 4 <br /> t" ` W - r n t i Township Range Section <br /> VE V, Lat ? a p a0 N Long I ' W <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH NEW WELL <br /> ' N T i I A N 0 1 A MODIFICATION/REPAIR <br /> ( — Deepen <br /> _ Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> SCE SITE MAP Under"GEOLOGIC LOG') <br /> w A <br /> A^ T A C H USES() <br /> WATER SUPPLY <br /> ti ,,)�,,, _ Domestic _ Public <br /> Irrigation _ Industrial <br /> WMONITORING <br /> I TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> Fences,Rivers,etc.and attach ama Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER N A —(Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL NA (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD r�,n,(GPM)&TEST TYPE � <br /> "TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN N A (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL _4- (Feet) *May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE() FROM SURFACE TYPE <br /> HOLE <br /> DIA. Y z x a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) z w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m N 0:3 LL (Inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (�) (TYPE/SIZE) <br /> I I <br /> I I <br /> , <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 Log <br /> Well Construction Diagram NAMEr,te�} <br /> (PER ON, FIRM,ORMCORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) t� <br /> Soil/Water Chemical Analyses i V C K 1. E 'tt t i t '? C f <br /> Other <br /> ADDRESS CITY STATE ZIP <br /> '�j'` �' . <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />