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UADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> • or Local Requirements , WELL COMPLETION REPORT <br /> Page ( of ;' Hrfer to Instruotrnu Pamphlet STATE WELL NO/STATION NO <br /> _ <br /> NO <br /> Owner's Well No I' <br /> 703977 LATITUDE LONGITUDE <br /> D lte Work Began Ended y <br /> Local Permit Agi II <br /> Permit No r 1 ` I,(,nnit D atc, r APN1TRSIOTHER <br /> GEOLOGIC LOC WELL OWNER <br /> ORIENTATION (✓J _VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) N 11T1e — <br /> DRILLING N1 Tillll Address <br /> DEPTH FROM METHOD FLUID r <br /> sURFACE DESCRIPTION <br /> Ft to Ft 1)(541111( mert(l ial gl ain Si "(dol &t(, CITY STATE ZIP <br /> WELL LOCATION <br /> ,J1 Address <br /> l County <br /> 1 APN Boal. Page P lrcel <br /> Tovntilnp H Tnbe Section <br /> LatlhlC e I I NORTH LonQlhldC I I WEST <br /> DEG MIN SEC b DEG MIN SEC <br /> LOCATION SKETCH ACTIVITI I <br /> NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> I I _ Deepen <br /> Other(Specify) <br /> I I <br /> DESTROY(Describe <br /> i Procedures aad Materials <br /> rf" Under GEOLOGIC LOG f <br /> F~ PLANNLD USES (�) <br /> I I WATER SUPPLY <br /> Domestic Public <br /> Irrigation Industrial <br /> H­ <br /> Lu <br /> w MONITORING <br /> I I TEST WELL <br /> I I CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> i I DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Illnstini or D(srnbr Dlstanr( ofl`11(11 from Roads Bulldno's <br /> FLLLS Ritcrs ei awl attarh nm 9( rtdditrnna latir1f OTHER(SPECIFY) <br /> na > <br /> nccessnrrf PLEASE BE ACCURATE&C031PLET� r <br /> I I <br /> WATER LEVEL & SIELD OF CONIPLETED WELL <br /> I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i I DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> r CAI D1 PTH OF BORING (Fec t)rTEST LENGTH (Firs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPT11 OF COMPLErND IVELt (Feet) *Allay not bt zeptesezztatrze I a well's Inngr-term yield <br /> DEPTH CASINC (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HORS TYPE FROM SURFACE TYPE <br /> DIA Y z o MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN <br /> (inches) g ¢ zoo (',RADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> FL to Ft m N cep (inches) THICKNESS {Inched Ft to Ft (TYPEISIZE) <br /> LL (�) (2�) (2�) <br /> ✓ <br /> I/ } <br /> ATTACHNILNTS (2�) CLRTIFICATION STATEMENT <br /> Geologic Log ! the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME " — — <br /> Geophysical Log(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY � STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> WELL DRILEERlAOTHORITEO REPRESENTATIVE )ATE SIGNED TTI LICENSE NUMBER <br /> Dtut tis RLt 11 97, IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />