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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File vi DW WELL COMPLETION REPORT <br /> Page Of I Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Ownei's Well No No El7$51 �l5 I F1 El <br /> Wto <br /> Work Began O Ended LATITUDE LONGITUDE <br /> eal Permit Agency ^A N, <br /> Perrnit NOPermit Dae APNITRSIOTHER <br /> � D <br /> GEOLOGIC LOG C\ kLL OWNER <br /> ORIENTATION DFi3LLINGTICAL.. 11—HORIZONTAL —ANGLE n1(SPECIFY) Nae ,,]]} } �* <br /> DEPTH FROM METHOD FLUID L.ng'A dtVn.N <br /> SURFACE DESCRIPTION '`o< �•.r' QA <br /> Ft to Ft Describe material grain size, color etc "�S�`�S'1 ai [ STATE ZIP <br /> LbCATIO <br /> 4 � �Acldr�ss <br /> 1 t I-Ti(,oun`ty i <br /> 'APBook Page Parcel <br /> �W <br /> a Towr4hiP �� Range Section I <br /> ' La6tude <br /> 0 � , NORTH Longitude I 1 WEST <br /> DEG <br /> \`4 MIN SEC DEG MIN SEC <br /> r- LOCATION SKETCH -ACTIVITY 0�:) <br /> t NORTH NEW WELL <br /> 5a 5T MODIFICATION/REPAIR <br /> Deepen <br /> _ Other(Specify) <br /> t iDESTROY(Describe <br /> ,�,� Procedures and Materials <br /> r - /� 1 !V Under GEOLOGIC LOG) <br /> 31 ` Iv PLANNED USES (2�.) <br /> WATER SUPPLY <br /> r F-IM��1l LVG - Domestic _ Pubfic <br /> U) J�41'1/`�� _„_,_ Irrigation _ Industrial <br /> t i W <br /> i MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> .34 HEAT EXCHANGE <br /> t r DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> I r SOUTH <br /> Illustrate or Describe Distance of Wel[{ram Roads Buildings REMEDIATION <br /> r Fences Biters etc and attach a map, Use additional paper if OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE U COMPLETE <br /> WATER LEVE_L & YIELD OF COMPLETED WELL <br /> I t DEPTH TO FIRST WATER t) BELOW SURFACE <br /> DEPTH OF STATIC <br /> F WATER LEVEL (FI)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING {Feet) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) TEST LENGTH (His) TOTAL DRAWDOWN (Ft) ^— <br /> May not be representative of a well's long-term yield <br /> DEPTH CASING (S) <br /> FROM SURFACEBORE ANNULAR MATERIALHOLE TYPE(—') FROM SURFACE rYpE <br /> DIA x z ¢ a MATERIAL! INTERNAL GAUGE SLOT SIZE <br /> (Inches) Z w z� a GRADE DIAMETER OR WALL IF ANY CE BEN <br /> Ft to Ft IM ¢ U MENT TONITE FILi FILTER PACK <br /> IM 11 C z (Inches) THICKNESS (Inches) Ft to Ft (TYPEIStZE) <br /> (2�) Of:) (Z�) <br /> ~J s1 / <br /> VI sI N <br /> t <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> 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 4 } <br /> Geophysical (PERSON FIRM OR CORPORATION) (TY OR PRINTED) <br /> P ysical Log(s) �� <br /> _ SOII/Water Chemical Analyses S <br /> Other ADDRESS CITY <br /> 1 a STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed vL1a Y 'RJ D <br /> W <br /> DRILLER <br /> JA <br /> REPRE TATIVE DARE SIGfjfD C 57 LICENSE NUMSE <br /> DWR 188 HEV 1197 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />