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QUADRUPLICATE STATE OF CALIFORNIADWR 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. No. 0989448 <br /> Date Work Began It Ended 11 <br /> LATITUDE LONGITUDE <br /> Local Permit Agency ;A N �A i: ::lW co {`j�� Hn APN/TRS/OTHER <br /> Permit No. p ri r'7. '"` t Permit Date_;o I!9 I C <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION __.L VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Name 5 :t d L KJONII'" t ! '+. '• 1 - <br /> DRILLING <br /> DEPTH FROM METHOD +'1 ti AV G j FLUID %'A 0 N Mailing Address !Irk j <br /> SURFACE DESCRIPTIONn a <br /> Ft. to Ft. Describe material, grain size, color, etc. <br /> CITY � T STATE ZIP <br /> WELL LOCATION <br /> 1 Address <br /> City ; Toc (zTn �� <br /> County (, AN T t A, ri 1.'I N <br /> APN Book11-4 1 Page 20 Parcel ?. <br /> T Township Range Section <br /> r - <br /> Z r Lat } l P I r a, � Long —l i I `� t I t}?t ! w <br /> I DEG M MSEC. DEM SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> 1 NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> ' _ Other(Specify) <br /> fr R <br /> r <br /> DESTROY(Describe <br /> IProcedures and Materials <br /> i t F MAP Under"GEOLOGIC LOG-� <br /> USES(.!L) <br /> 'A C r A IT A c ki WATER SUPPLY <br /> Domestic _ Public <br /> F F _ Irrigation _ Industrial <br /> W a MONITORING <br /> W <br /> TEST WELL <br /> 1 CATHODIC PROTECTION_. <br /> I HEAT EXCHANGE <br /> DIRECT PUSH <br /> I I INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH <br /> I I REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> 1 Fences,Rivers,etc.and attach a map Use additional paper f OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL �J Fi (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD - N%\ (GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORING El (Feet) TEST LENGTH *'j t' (Hrs.)TOTAL DRAWDOWN N jl. (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL _(Feet) *May not be representative of a well's long-terra yield. <br /> CASING (S) ANNULAR MATERIAL <br /> FROM SPU FACE TH BORE- TYPE( ) FROM SURFACE TYPE <br /> HOLE <br /> DIA. flTww"_ <br /> Cr a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN-'(inches) � a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILLFILTER PACK <br /> Ft. to Ft. � (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> o LL (✓) (✓) ('�) <br /> I I <br /> I I <br /> t ,Ii <br /> T RA <br /> I I <br /> I 1 <br /> ATTACHMENTS (_1) 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 NAME '- r., �'t . <br /> (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses Q L 4 L ,, A <br /> Other� 1T F til A O ADDRESS 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 />