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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWRl. 1r WELL COMPLETION REPORT i i I i i 1 i = <br /> Page Of • Refer to Instruction Pamphlet STATE WELL NO(STATION NO <br /> Owner's Well No At"1 � - No <br /> 7851 <br /> 7 8 LATITUDE ❑ LONGITUDE 1:1Date Work Began Ended <br /> �A@ <br /> Local Permit Agency <br /> l�i / - - APNITRSJOTHER <br /> Permit No OQZ91LO —Permit Date 11 <br /> GEOLOGIC LOGWELL OWNER <br /> ORIENTATION (zL jk VERTICAL ^HORIZONTAL _Y._._ANGLE ...r(SPECIFY) Name\ <br /> DRILLING L1Cd <br /> METHOD 1!E] FLUID Mailing Adc ss t <br /> DEPTH FROM ) 1 <br /> SURFACE DESCRIPTION \ <br /> Describe InateriRl grain size color etc CITY � r.� ti STATE ZIP <br /> Ft to Ft ''�' W L LOCATION <br /> r I -Addr'e�S r a <br /> �city. <br /> 25-157 1.,o CA"eAl*'54VjA0 S2 Ll— fG'o�un r <br /> 2s I L �` y "v - �APN BookPage��Parcel <br /> i r S A t` h °" Township Range GILZ- Section <br /> I i f/ I NORTH Longitude I I wEs7 <br /> i t ✓° k t �'�,, - DEG MIN SEC DEG MIN SEC <br /> Z LOCATION SKETCH ACTIVITY (�) <br /> NORTH X NEW WELL <br /> MODIRCATIONIREPAIR <br /> t I Deepen <br /> Other(Specify) <br /> I J <br /> _ DESTROY(Describe <br /> Procedures and Mate Matenafs <br /> Under GEOLOGIC LOG) <br /> 'gyp, PLANNED USES 1-!L) <br /> i r O WATER SUPPLY <br /> ___. Domestic - Public <br /> IV""1i F Irrigation _ Industrial <br /> ul <br /> i w MONTORING <br /> TEST WELL <br /> CATHODIC PROTECTIOt <br /> i <br /> i I HEAT EXCHANG <br /> f� <br /> DIRECT PUSH <br /> INJECTION <br /> r i VAPOR EXTRACTION <br /> i i SPARGING— <br /> t I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads Buildings OTHER(SPECIFY)_ <br /> t I Fences Rivers etc and attach a nurp Use addatonal paper:�1 <br /> necessanf PLEASE BE ACCURATE U COMPLETE <br /> I L <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> 1 r <br /> i r DEPTH TO FIRST WATER W (Ft) BELOW SURFACE <br /> t DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> I ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Fe t) TEST LENGTH (Hrs) TOTAL DRAWDOWN - (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representatme of a well's long-term yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE FROM SURFACE TYPE <br /> TON- <br /> MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> GRADEDIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft � (Inches) THICKNESS (Inches) FI to Ft (TYPE/SIZE) <br /> 0 LL (2:L) (IL) ('L) <br /> ll A �� I <br /> I V <br /> I <br /> I 1 <br /> 43 sanA <br /> I 1 <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> — Geologic Log <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief Well Construction Diagram NAME(PERSON Vi- <br /> fwd DR Cb OC DN) PED OR PRINTED) <br /> RM <br /> _ Geophysical Log(s) <br /> _ Soil/Water Chemical Analyses ! F1 cbnl - <br /> ADDRESS CITY STATE ZIP <br /> — Other �/,/ i r Q <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed �/T�/[J <br /> DRILLERlAU HORIZE PRESEN IVE D E SIGNED C 57 LICENSE NUMBER <br /> DWR IRA REV 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />