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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—of, Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. M W 7 No. 0989452 <br /> Ended 11 <br /> Date Work Began 11 �� 1 S I��, -i( l � LATITUDE LONGITUDE <br /> Local Permit Agency !t( T n AU i N CU i!�1 T�r k�D <br /> Permit No. S ,091�c 3 4 Permit Date i 0 i!f �t APN/TRS/OTHER <br /> 8 <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) Y VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name e T L O�r a'M ,"�H y RV F O 1_t T A N <br /> DRILLING {y y� `, T <br /> DEPTH FROM METHOD 1l 5 A U b 6 FLUID N Q 14 t^ Mailing Address C'0 y A I E P W A�j <br /> SURFACE DESCRIPTION C A C7 C) <br /> Ft. to Ft. Describe material, grain size, Color, etc. CITY `` —� STATE ZIP <br /> WELL LOCATION <br /> Address f .y+1! ( E: <br /> City hl <br /> % taCF.( a <br /> County 5 A N 7 UA('LV I C4 <br /> APN Book1 1 Page '760 Parcel -3i <br /> t (' Township Range Section <br /> r <br /> I I _ 1 Lat '�� I Q� 1 2 I , z N ' 2 L � , w <br /> DEG. nnl sEc. Long _ to G. I M1N.4} I }src <br /> LOCATION SKETCH ACTIVITY (�1 <br /> IUE Yr NORTH _ NEW WELL <br /> ANQt <br /> MODIFICATION/REPAIR <br /> `.qAU 9 liki WE _ - IT "t" Deepen <br /> I..(v r• L ! I Other(Specify) <br /> DESTROY(Describe <br /> f /� Procedures and Materials 1 C J i T E M A r Under"GEOLOGIC LOG") <br /> =* I n t�t <br /> USESO <br /> , f G A C I A C r6 L D WATER SUPPLY <br /> fACJ C> 1 ( — Domestic _ Public <br /> Irrigation _ Industrial <br /> n � <br /> '-`' a MONITORING <br /> � w <br /> TEST WELL <br /> I I CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> ' I DIRECT PUSH <br /> INJECTION <br /> I VAPOR EXTRACTION <br /> SPARGING_ <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings <br /> Fences,Rivers,etc.and attach a map Use additional paper ily OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER { -' (Ft.) BELOW SURFACE r <br /> DEPTH OF STATIC N <br /> WATER LEVEL ' A (Ft.)&DATE MEASURED N <br /> I I � n <br /> ESTIMATED YIELD i A (GPM) &TEST TYPE N <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH <br /> Iy AA (tits.)TOTAL DRAWDOWN_(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL ---6-0—(Feet) *May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE (TYPE ) FROM SURFACE TYPE <br /> DIA. x w o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z zoo J GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m coo (Inches) THICKNESS (Inches) Ft. to Ft. ( L) (.!L) <br /> ( L) (TYPE/SIZE) <br /> LL <br /> I I <br /> I I <br /> I \ )•' r1 l� I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> .;LGeologic Log I, the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME U d -I R I L <br /> O(N s' k,4 Q , <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses I R Q`� b U C� L��.1 4K [)R k Y r S i 0 G k T b N CA y 2 f <br /> Other 511E hal A F ADDRESS � J _ _ <br /> ,.' CITY STATE ZIP <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 />