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l <br /> QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page_of i Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. w-�- No. 0989454 <br /> Date Work Began l i Ended � <br /> +--��2 is LATITUDE LONGITUDE <br /> Local Permit Agency ti A N d V n Cl V;N ICU U N T Y � ii L' <br /> F1 111111111111 � <br /> Permit No. S K t 0:1 35?f Permit Date 10 11 t 9� (� APN/TRS/OTHER <br /> / GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) ✓VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Name S I O C R T U N M(f T(7 U P G l I T A N A I N P U N T <br /> DRILLING I ) Mailing Address 0 Q l �� h 0 W A' <br /> DEPTH FROM METHOD l'1 S n�C .. ,-. FLUID i�l t,♦w F g a f � �Y i <br /> SURFACE DESCRIPTION `,T0 t'k T t, M CA �9 2 D 6 <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY STATE ZIP <br /> WELL LOCATION <br /> Address 27 5 I p4�C. t' Ei Imo(c;N_ <br /> City 5TcCt�T4N <br /> county S A NN 1,1A i V I N <br /> ' APN Book I:t I Page 6r Parcel 31, <br /> r Township Range Section <br /> 2,4 1 C rTM Lat l�`� I i (I t in Long I 1 I I g 4 �G W <br /> DE MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH <br /> 1 NEW WELL <br /> 'N Ll. VJAr' IL L Q W 11 N A I MODIFICATION/REPAIR <br /> I IL`V MINT TU �JEET '1 Itl IT _ Deepen <br /> _ Other(Specify) <br /> I <br /> -:'_ DESTROY(Describe <br /> - .r. Procedures and Materials <br /> 5 1' C ( ITE <br /> E r�l A P Under"GEOLOGIC LOG') <br /> PSI' r C C �J 1 1 '!. USES(�) <br /> i I <br /> !� I A C WATER SUPPLY <br /> P Domestic Public <br /> Irrigation Industrial <br /> CD <br /> ' 1 - WITH A 3 < MONITORING— <br /> LLI <br /> TEST WELL <br /> T CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> _ DIRECT PUSH <br /> t <br /> i <br /> INJECTION <br /> VAPOR EXTRACTION <br /> f*,4pArJJD 56jL l } 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 if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I ��q <br /> DEPTH TO FIRST WATER=1A (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC L <br /> WATER LEVEL 1`1 A (Ft.)&DATE MEASURED I y A <br /> ESTIMATED YIELD ' INIA (GPM)&TEST TYPE �. <br /> TOTAL DEPTH OF BORING 0 (Feet) TEST LENGTH__aA_(Hrs.)TOTAL DRAWDOWN(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL __k_Q_(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 ¢ a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) z w iE a DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MENT TONITE FILL <br /> Ft. to Ft. m ti o0Q LL (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> (�) (�) (�) <br /> i I <br /> i I <br /> r <br /> I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> _bL <br /> r Geologic 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 V 4 W DR I l t i N G I N 1, <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) I, j PR <br /> WE Chemical Analyses LI C,t' C f' i- �1"� P R�V E 5 T o C K T O N . / i <br /> � <br /> ADDRESS CITY TATE ZIP Other � , ")AP <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 />