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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR OLL COMPLETION REPOR <br /> Page_L_of I Refer to Instruction Palnplilet I' STATE WELL'.INO_//STATION NO. <br /> Owner's Well No. <br /> O. 701756 LATITU <br /> WINGITUDE <br /> Date Work.Began , Ended <br /> Local Permit Agency z. 4�. <br /> APN/TRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Ir <br /> DRILLING �{ p <br /> DEPTH FROM METHOD A. FLUID Mailing AddreSS <br /> SURFACE DESCRIPTION Ti --,4 p1 X77` <br /> Ft. toFt. Describe Material, grain SiZe, Color, etc. CITY STATE ZIP <br /> I 7V <br /> NIIFL nATIg� <br /> 1 I Address - 2-0500 O (V ✓`ttJ.p <br /> City <br /> I County 1.1t e�aa <br /> 1 I APN Book Page Parcel <br /> I I Township Range Section <br /> I I Latitude 1 I NORTH Longitude I WEST <br /> 1 DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCHACTIVITY (�) <br /> NORTH � NEW WELL <br /> I I <br /> MODIFICATION/REPAIR <br /> Deepen <br /> I — Other(Specify) <br /> 1 co"h$� DESTROY(Describe <br /> 1 <br /> Under <br /> ProceduresGEOLOGICMaterials <br /> LOG') <br /> I I <br /> PLANNED USES (�) <br /> I 1 ® WATER SUPPLY <br /> — Domestic _ Public <br /> fJ! I r 0 U1 W _ Irrigation _ Industrial <br /> C H <br /> w Q MONITORING <br /> 1 oel, TEST WELL <br /> I CATHODIC PROTECTION <br /> 1 HEAT EXCHANGE <br /> I DIRECT PUSH_ <br /> INJECTION <br /> •7 VAPOR EXTRACTION <br /> I <br /> . SPARGING_ <br /> 1 SOUTH REMEDIATION <br /> -- Illustrate or Describe Distance of Well from Roads,Buildings, <br /> I Fences,Ricers,etc.and attach a nutp [Ise additional 1)aper if OTHER(SPECIFY) <br /> necessanl.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 1 DEPTH TO FIRST WATER S(Ft.) BELOW SURFACE <br /> 1 1 DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I 1 <br /> ESTIMATED YIELD " (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) <br /> TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL __�,3 Q_(Feet) May not be representative of a well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPEO FROM SURFACE <br /> TYPE <br /> DIA. Y w . a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BE <br /> m Uo? GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. g (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> (n LL (2�) (ZL) (2!L) <br /> I <br /> I <br /> t M I <br /> I I♦ <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I, the uncle signed,c, ify that t is report is com <br /> Geologic Log plete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME <br /> ( <br /> _ Geophysical Log(s) ER FIR OR RPORATIO OR PRINTED) <br /> f M I �,(ry�` <br /> Soil/Water Chemical Analyses f YL(] <br /> Other ADDRESS f i CITY STATE ZIP <br /> i 1 1" <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed WELL RILLER/AUTN RIE EPRESEMATIVE DAT SIGNED rC�ICENSE NUMBER <br /> DWR 188 REV. 11-9s IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />