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• OVADRUPLICATE STATE OF CAI IFORNIA Own USE ONLY DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page I of I R<ftr to lnslirictlarl Pamphlo STATE WELL NO/STATION NO <br /> Owner'sWell No No <br /> 703979 <br /> D AG Wolk Began v Endcd 1 LATITUDE LONGITUDE <br /> — ) <br /> Local Peltnit Agcne Y '<< r Z J I <br /> Pennit No � Permit Date r APNlTRS10T <br /> HER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) 7 <br /> i�dnle <br /> DRILLING , N1 Tlling Addles <br /> QI FROM METHOD FLUID z, x <br /> SURFACE DESCRIPTION <br /> Ft to FI colo! (t( CITY STATE ZIP <br /> WELL LOCATION <br /> ' Address - <br /> City - <br /> County <br /> _ APN Book Page Parcel <br /> t Township R Inge Section <br /> t _ <br /> Latitude I I NORTH Longitude I I WEST <br /> 1 DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITI (�) <br /> r I NORTH NEW WELL <br /> I <br /> MOD)FICATIONlREPAIR <br /> I I _ Deepen <br /> i _ Other(Specify) <br /> DESTROY(Describe <br /> I I Procedures and Materials <br /> Under GEOLOGIC LOG J <br /> I - PLANNED USES (.!!L) <br /> I I WATER SUPPLY <br /> I I Domestic Public <br /> F Irrigation IndusMal <br /> rn <br /> IQ MONITORING <br /> ' TEST WELL <br /> I I CATHODIC PROTECTION <br /> I I <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH_ <br /> INJECTION <br /> VAPOR EXTRACTION I <br /> I r SPARGING <br /> SOUTH REMEDIATION <br /> llhntrnt( orpo(nbt Dislancc of lSUl from Road, Brtrfth I� <br /> [ I Fences Bit,Is rtr awl allacha nirr77t Usr a(Irlehoaal77xe(tcr f OTHER(SPECIFY)— <br /> neccssanf PLEASE BE ACCURATE&COMPLETE <br /> I I <br /> WATER LEVEL & IIELD 01 COMPLETED WELL <br /> I I <br /> I I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> I I WATER LEVEL (Ft)&DATE MEASURED <br /> l ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOfA[ 1)1 I TE3 OF 130EiINC (hL�t� TEST LENGTH (Hrs}TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF CONIPLN f D It P LL (Feet) May not he ttptest ntattvt of it well's long-team yield <br /> DEPTH CASING (S) DEPTH ANNULAR ;IATLRIAL <br /> FROM SURFACE HOLE TYPE(—' ) FROM SURFACE TYPE <br /> DIA Y z a MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> (inches} ¢ 0r a GRADE DIAMETER OR WALL IF ANY ME NT TONITE FILL FILTER PACK <br /> Ft to Ft m N coo - (Inches) THICKNFSS (inches) Ft to Ft ( �) ( � ) ( �) (TYPE/SIZE) <br /> LL <br /> I r <br /> I ) I <br /> I { I <br /> I <br /> I • I <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 <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logs) <br /> Sod/Water Chemical Analyses <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION IF 1T EXISTS Signed <br /> WELL DRILLERMILITHOR170 REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> DNR 1Sa III\ 1197 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />