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<br /> s ORIGINAL STATE OF CALIFORNIA "-^ DWR USE ONLY — DO 'NOT FILL 'IN i
<br /> File with DWR WELL COMPLETION REPORT
<br /> Refer to Instruction Pamphlet STATE WELL.NO.ISTATION NO.
<br /> Page—of MWii7,3 4 5r6 �ZI � : No. 0931774
<br /> Owner's Well No. W~(5.I l�. S. 6. 3.
<br /> Date Work Began I C 1 j -f Ended +a'11 8 1,0 4 ;LATITUDE LONGITUDE
<br /> Local Permit A ency SAN 4-CA A VF COV ff'J,L N D
<br /> r..,r APNrrRSIOTHER
<br /> Permit No. 1Z 1{0 d S 1$ $ Permit Date -
<br /> GEOLOGIC LOG ° { ,y ,WELL OWNER
<br /> r w /
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<br /> ORIENTATION {✓} VERTICAL HOMZONTAL _ANGLE —(SPECIFY) Namo �+ �+ O " G ''� �'I 1✓
<br /> DRILLING N A " 14 Marling'Add ss, P h 6�.s13`0�'_ .,!'� 3 I
<br /> DEPTH FROM METHOD FLUID
<br /> SURFACE DESCRIPTION ;-,t, '`5 r OaG `fit7 .�, A �/�9 '� ( -
<br /> Ft, to FI_ •l �OITY. STATE .'ZIP
<br /> Describe material, grain size, color, efc .-�,�,,F � r. 'v, � ,j
<br /> WELL LOCATION'
<br /> Address X114 ft I7 f,N Ir. C ft M 1e'T R y LANE
<br /> I 17 S k i SCity M V 14 C Ek T. 1�1 C
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<br /> I CA SP_ CLGS Vl ''��. ''`� : ,G''oun ' 5A0 "T,"D A'CL i 1N! -
<br /> > "" * a'A-PN Book 1 Z Page -4�x Parcel Q A Z
<br /> THE W s ' E�.s,is V,I� .',"°,s Township_ Range Section
<br /> C-R O v 7 : W it E � '1T�C t. t N h Lai s I N Long I I w
<br /> DEG. MIN. SEC., DEG.' MIN. .'SEC.
<br /> 1-Ci'd:• .pE!1 �. �y0 �; ,(l1 LOCATION SKETCH ACTIVITY.{�) 11
<br /> NEW WELL.
<br /> I I +_.°�w -`y. '� \-1• ' MODIFICATIONIREPAIR
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<br /> 'A P, VOX) -• y.'¢";' A'1 j15 ,Ori"�y' ` �+ [ i AMP — Deepen
<br /> ;1<.. N �T 5 Ag it �t,Vt E A C ` 1 E E J 1 T t PLAN A M p Other[SpecitYl
<br /> 1 w,l_.•t..�*`��4 S?[- V :.art•^•:1 f�V I� (µ 1 i� DESTROY(Describe
<br /> r ,•-;,.} �1 f� T ■1 p Procedures end Malerials
<br /> E '9 P A 1`t P F-D 1 l E d{-4 r7 N Under"GEOLOGIC LOG")
<br /> r
<br /> USES(!)
<br /> E
<br /> (ATIAcNea)
<br /> I
<br /> \4-114E 1N,E 1., Of t S .0 VPEER WATER SUPPLY
<br /> I Ifes." Domestic Public
<br />. E( Et Q G I' - Ir�� f- Irrigation Industrial ,
<br /> En
<br /> I I X W d Ah M%1 i IJ ANP{{ p A L : OI�. '1S T 3 ¢ MONITORING
<br /> I I ADP IT 16 H � .
<br /> .G'I* ' WAS
<br /> T WELL J
<br /> I I I N s 4 LL t tz 17 'R M` ly�H 1\0 0 CATHODIC PROTECTION
<br /> /y HEAT EXCHANGE
<br /> I I C!� DIRECT PUSH
<br /> i I I INJECTION
<br /> f I I F- A- {tlLD 6 P L k I VAPOR EXTRACTION
<br /> A C TllA l SPARGING—
<br /> I I u- r^ �{ V L rr Qi� SOUTH REMEDIATION
<br /> L - I(iustrrite or Describe Distance of Well from Roads,Buildings
<br /> L fences,Rivers,etc.and attach a utas.:Use additiarraI paper et OTHER(SPECIFY)
<br /> \JOLUKPISnecessary.PLEASE RE ACCURATE&COMPLETE,
<br /> I +
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<br /> WATER LEVEL &'YIELD OF COMPLETED WELL
<br /> I I DEPTH TO FIRST WATER (Ft.) BELOW SURFACE -
<br /> I I DEPTH OF STATIC NA
<br /> WATER LEVEL (Ft.)&DATE MEASURED
<br /> ESTIMATED YIELD ' '(GPM) &TEST TYPE
<br /> TOTAL DEPTH OF BORING (Feet) Y A R 10 V 5 TEST LENGTH (Hrs.)TOTAL DRAWDOWN - (Ft.)
<br /> TOTAL DEPTH OF COMPLETED WELL — (Feet) : `May not be representative of a.well's long-term yield.. l
<br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL
<br /> HOLE (
<br /> FROM SURFACE BORE TYPE ) FROM SURFACE TYPE I
<br /> DIA. x x a MATERIAL/ ENTERNAL GAUGE 5LD7 SIZE CE. BEN.
<br /> - FILTER PACK
<br /> (Inches) z z a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL
<br /> Ft. to Ft, cgQ - (Inches) THICKNESS (Inches) Ft. to Ft. {�) (✓) { } (TYPEISIZE)
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<br /> ATTACHMENTS CERTIFICATION STATEMENT
<br /> I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief.
<br /> V Geologic Log
<br /> Well Construction Diagram NAME .,TDA ' R A M A-6-E FOR D D V L O S E kI V I S O N M E NTA.L, INC. I
<br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED)
<br /> Geophysical Log(s)
<br /> SeiVWater Chemical Analyses PA R O X 2 0 R A,4 Cr F V h L6, C A 3 5 6 Eo 1 )
<br /> Other MA PS TA b L t ADDRESS CITY STATE R nzip
<br /> ATTACH ADDIT10NAt_ INFORMATION, IF 1T EXISTS. SignedIL
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<br /> ` O 4 V'�
<br /> C-57 LICENS D WATER WELL CONTRA OR DATE' IGNED C-57 LICENSE NUMBER
<br /> DWH 188 REV.05-u:3 IF ADDITIONAL SPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 ,
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