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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements EELL COMPLETION REPOR'. I I I I I 1 1 1 1 1 1 <br /> Pageof Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Oer's Well No. No. <br /> wn0927011 <br /> 92701 <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agenc\ <br /> APN/TRS/OTHER <br /> Permit No., l Permit Date ��( <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING <br /> DEPTH FROM <br /> METHOD lk FLUID �_ - A Mailing Address <br /> SURFACE DESCRIPTION ;_�_ <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY � -- STATE ZIP <br /> WELL LOCATION <br /> Address I,S.,,,,��� _ <br /> .( City <br /> A. <br /> County <br /> APN Book Page t 6ic Parcel <br /> Township Range Section <br /> Lat �I —7 N Long "' j �" a�..�°, I w <br /> DEGZ. - --MIN: _S9C_ DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (=L) <br /> i I NORTH �NEW WELL <br /> MODIFICATION/REPAIR <br /> _ Deepen <br /> Other(Specify) <br /> i I <br /> _ DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> — USES( ) <br /> 1•; WATER SUPPLY <br /> u� Domestic Public <br /> A ,I F Irrigation Industrial <br /> '( w. MONITORING <br /> TEST WELL <br /> l � CATHODIC PROTECTION <br /> C� t-;• y; ,',1 HEAT EXCHANGE— <br /> \t 7 DIRECT PUSH <br /> f INJECTION <br /> ' I VAPOR EXTRACTION <br /> SPARGING <br /> i I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well front Roads,Buildings, <br /> i I Fences,Ricers,etc.and attach a map. Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE dr COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.)BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING �� E' (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL `: '� � (Feet) *May not be representative of a well's long-term yield. <br /> DEPTH BORE- <br /> CASING (S) DEPTH ANNULAR MATERIAL FROM SURFACE HOLE TYPE(—) FROM SURFACE TYPE <br /> DIA. r w ¢o a MATERIAL/ NTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z w zF 'a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m V �� (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> I � <br /> I I„ <br /> I � <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 /> Geologic Log <br /> Well Construction Diagram NAME t <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> SoilM/ater Chemical Analyses i S s 1 4 t T•' _ �" T�,A-r <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />