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ORIGINAL. STATE OF CALIFORNIA DWR USE ONLY Do NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page L of j— Refer to Instruction Pamphlet STATE WELL NO ISTATION NO <br /> Owner's Well No No �y Q �} "]7 <br /> Weal <br /> Work Began 2 1 Ended ( r 87 .L ( LATITUDE LONGITUDE <br /> Permit Agency j 4 aa�tg <br /> Permit No _06 //b Permit Date APNlTRSlOTHER <br /> 78' <br /> GEOLOGIC LOG rW LL OWNER <br /> ORIENTATION (z�) A/VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Naitv <br /> DRILLING Ma11uT 'AddTress <br /> DEPTH FROM METHOD FLUID g r <br /> SURFACE DESCRIPTION _ ,✓' ~ 04 <br /> Ft to Ft DeSGrtbe inaterral grain stye color etc ' STATE ZIP <br /> 414 C1 <br /> a� IiLL LOCATI N <br /> �c�dr�ss <br /> I , 45 41- `,'' '� � '� ter, "JV­ <br /> I'D <br /> A !!u IDU�ounty� <br /> r w �� 1� � <br /> � �APN Book Page Parcel �D <br /> 3a Town�hlp "Z,/V Range_9611 Section s <br /> r a�itude I I NORTH [,Ongltude I I WEST <br /> I rS I Sl � C' t''~ °�,,�� 'r r - DEG MIN SEC DEG M!N SEC <br /> r 4 LOCATION SKETCH ACTIVITY <br /> NORTH NEW WELL <br /> 1 MODIFICATION/REPAIR JqZ <br /> t � "x.,. Deepen <br /> _ Other(Specify) <br /> DESTROY t. 3 <br /> Oescribe <br /> Proced res{and Materials <br /> Under GEOLOGIC LOG} <br /> ^10J-3 PLANNED USES (.!:L) <br /> I I WATER SUPPLY <br /> Domestic Pubhc <br /> Irrigation Industrial <br /> to <br /> uj <br /> t I ti J�_p� j W MONITORING <br /> t I � lW <br /> 3 TEST WELL— <br /> CATHODIC PROTECTION <br /> I I HEAT EXCHANGE <br /> I I <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> ' r SPARGING_ <br /> I i SOUTH REMEDIATION <br /> Illustrate or Dawnbe Distance of Well from Roads Buildings <br /> 1 ! Fences Ricers etc and attach a awp Use additional paper:f OTHER(SPECIFY) <br /> necessattj PLEASE HE ACCURATE lr COMPLETE <br /> I t <br /> I 4 <br /> WATER LEVEJ, & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> 1 I <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> t I ESTIMATED YIELD (GPM) &TEST TYPF. <br /> TOTAL DEPTH OF BORING (Feet TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's lom&tern yield <br /> DEPTH CASING (S) DEPTH BORE- ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(' FROM SURFACE TYPE <br /> DIA r z ¢ a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BEN <br /> Ft to Ft (Inches) z� o_ GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> m N "o :j (Inches) THICKNESS (Inches) F1 to F! (TYPE/SIZE) <br /> D lb" <br /> 40 AD `t D,DI " <br /> t <br /> Z <br /> I <br /> r , <br /> I , <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log <br /> 1 the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief Well Construction Diagram NAME— t kl M ll px <br /> Geophysical Log(s) <br /> (PERSON FIRM OR CORPORATION) PED OR PRINTED) <br /> T j�/� �'.{` �t �Q, <br /> _ SoiVWater Chemical Analyses rho S9% {!�le� C4 2-av1 <br /> Other ADDRESS CITY a STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed \ �� "� 'O Z D <br /> L DRILLER UTHOR D REPRES TATIYliliE D E SIG ED 57 LICENSE NUMBER <br /> DAVR 188 REV 11 sr IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />