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ORIGINAL STATE OF CALIFORNIA #=,TATE <br /> E ONLY — DO NOT FILL IN <br /> Rile with DWR OLL COMPLETION REPOR <br /> Page-L of�_ Refer to Instruction Pamphlet WELL NO./STATION NO. <br /> Owner's Well No. NO. 701755 F]Date Work.Began Ended LATITUDE ❑ LONGITUDE <br /> Local Permit Agency r !AN V An L4 i ".�L'f .,,�,. <br /> Permit No. Permit Dater APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) VERTICAL _HORIZONTAL — / <br /> DRILLING Q p —ANGLE (SPECIFY) Name <br /> DEPTH FROM <br /> METHOD 15A FLUID Mailing Address <br /> SURFACE DESCRIPTION TY1itn to, L <br /> _Ft. to Ft. Describe material, grain,size, color, etc. CITY _/jGE STAZIP 1 <br /> Address 2U5 ©VELE �1, 11 r\ �✓eL�r <br /> I #1 l <br /> Ci{y <br /> I � r <br /> County 14 <br /> A:PN Book Page Parcel <br /> Township Range--Section <br /> Latitude I NORTH Longitude-- WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH A,2TIVITY (�) <br /> NORTH ✓_ NEW WELL <br /> MODIFICATION/REPAIR <br /> _ Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> I I �4iM�L Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USES () <br /> WATER SUPPLY <br /> � I <br /> Domestic _ Public <br /> F Irrigation _ Industrial <br /> Lu MONITORING <br /> w <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> I HEAT EXCHANGE <br /> I I <br /> DIRECT PUSH <br /> INJECTION_ <br /> i I <br /> VAPOR EXTRACTION_ <br /> I i <br /> SPARGING_ <br /> SOUTH REMEDIATION_ <br /> -� Illustrate or Describe Distance of FVell from Roads,Buildings <br /> Fences,Ricers,etc.and attach a map.Use additional paper if OTHER(SPECIFY)_ <br /> necessanj.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER _A (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I i <br /> ESTIMATED YIELD ' (GPM) &TEST TYPF <br /> TOTAL DEPTH OF BORING —c�L�_(Feet) <br /> TEST LENGTH (Hrs.)TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL 3n (Feet) "May not be representative of a well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(`') FROM SURFACE TYPE <br /> DIA. r w a a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- - <br /> (Inches) g w� �� a GRADE DIAMETER OR WALL IF ANY MENT TBENBEN FILL FILTER PACK <br /> Ft. to Ft. ,o (inches) THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> I i <br /> i <br /> I � <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I, <br /> Geologic Log the un ersigne c that this report is coom Jlete and accurate to the best of my knowledge and belief. <br /> 1 1 <br /> Well Construction Diagram NAME I` r' C <br /> (P SON, FIRM, 0 CORPORATION) TYPE PRINTED) <br /> c x <br /> Geophysical Log(s) <br /> ) f' C • q <br /> _ Soil/Water Chemical Analyses `d' 1 s <br /> Other ADD ESS { CITY STATE ZIP <br /> Signed 11 <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. 9 L.' REPRESE TATIVE DAT SIGNE C-57 LICENSE NUMBER <br /> Days tas REV. 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />