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ORIGINAL <br /> File with DWR WELL COMPLETION REPORT <br /> Page I of J- lir fir to frystructyurr Yaa,yhlylI t <br /> STATE WELL NO/STATION NO <br /> Owner S Well No All lNo 0912982 LATITUDE LONGITUDE I <br /> Date b4ork Beg In�-fi)'' <br /> `� �_ , Endec .5-11-0- ii <br /> Local Pei mit �Qe*1G\ 50. 1 r i kU n �V,t, lka l � ���j��14 APNITRSlOTHER <br /> Permit No �' Permit Date <br /> WELL OWNER <br /> GEOLOGIC LOC � r � � <br /> ORIENTATION (�) _VERTICAL _HORIZONTAL —ANGLE �.,.,.(SPECIFY) Name ~� M r 1 li i ''� 'a n <br /> DRILLING <br /> 1 _ ,(U <br /> METHOD ° 4fLN:5 Ly1 L �I FLUkD qLN11amilin r Addy-asE �r�,DEPTH FROM sSURFACE DESCRIPTION � CITY STATE ZIP <br /> Ft to Ft Descrtbe material grain Stae color etc r��r'�`c WE L CATION <br /> I + wAddress �lIII �- �P n�, cr 01 <br /> 1 1 7.� -Fo <{, � i b <br /> e'�.r'� <br /> �APN Book ',' Page Parcel <br /> ~- Township f' Range Section <br /> " <br /> Long w <br /> DEG MIN SEC AEG MIN SEC <br /> LOCATION SKETCH A V1TY (�) <br /> I i C \``�` l }✓' 3 f -�� �^ NORTH NEW WELL <br /> MODIFICATIONIRE PAIR <br /> C <br /> SCCA"Id '51 k�klI - Deepen <br /> - Other(Specify) <br /> /' <br /> DESTROY(Oescrrbe <br /> ais <br /> Procedures UnderGEOLOGICLOG} <br /> !L <br /> USES <br /> WATER SUPPLY <br /> .^ Demestic _ Public <br /> 3rngahon Indusinal <br /> i I w ¢ MONITORING <br /> 3 LL <br /> i I TEST WELL— <br /> CATHODIC PROTECTION — <br /> HEAT EXCHANGE <br /> f t ' DIRECT PUSH <br /> i I INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> 11hatrate or Descnbe Distance of Well From Roads Buildings <br /> Fences Revers etc and attach amap Use additional ppaper a1 OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE&COAfPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH a a <br /> WATER TIC LEVEL ~] (Ft)&DATE MEASURED �r��'fy <br /> I ! <br /> ' ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING ._...—(Feet) TEST IrENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term YtEld <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE (—) FROM SURFACE TYPE <br /> HOLE TYPE � <br /> DIA x w a: n. MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) Z Z� 0. GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m N o�Q (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> r 4 fvc— s ki.` sc? 3 <br /> i <br /> TACHMENTS (:) CERTIFICATION STATEMENT <br /> I the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> ( — Geologic Log i '�+ <br /> L <br /> Well Construction Diagram NAMES ! t �it <br /> (PERSON FI DR CORPORATION) (TYPEDPRINTED) <br /> RINTEDI <br /> Geophysical Logs) 333 an aaf� Dr, � I SSS r <br /> /�6_o1UWater Chemical Analyses r <br /> — Other ADDRESS )) CITY STATE /.21P <br /> Signed ! c l f!'i 5.20-.�� �`��I Ei <br /> ATTACH AOOITIONA, INFORMATION IF IT EXISTS C 5l LICENSED WATER LL CDNT ACTOR DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 168 REV D5-O3 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM OSP D3 78836 <br />