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ORIGINAL STATE OF CALIFOR\IA DWR USE ONLY — 00 NOT FtLt IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page {— Pf 1 Refrr to InstrucNon Pamphl(I STATE WELL NO/STATION NO <br /> Owner's Well leo u— f 6 No 729679 LATITUDE 0 � <br /> Date 1�ori. Began 6 0 Ended If O 3q � LONGITUDE <br /> Local Pernut A!4encA Gt✓L. +'L � J^r► <br /> r r <br /> 1d 7 dV APN?RSIOTHER <br /> Permit 1\D Z�3S5 Permit Da#e 1 <br /> GEOLOGIC LOC !! WELL OWNER <br /> ORIENTATION ( r) ZIERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Nanic _t� e— C.-p. t-OAMC^ _ <br /> DRILLING �6 M <br /> DEPTH FROM <br /> METHOD FLUID ailing ddress <br /> SURFACE DESCRIPTION aICA a 571 <br /> FI to FI D(SCI tL( n!(!1(17(1l 'gI RIII Sh( color (1( CITY STATE ZR <br /> LV LL OCVTIO\ <br /> D D. Addiess 512- <br /> 0.3 O. Co"t cycle cit. <br /> 0.7 1 3 s c1 <br /> ConntN <br /> 3 APIN Book Page Parcel <br /> g �2f3 C Tommship Ranee Section <br /> 23 G8 51 144 Latitude I I --- NORTHWEST <br /> DEG MIN SEC DEG <br /> Lonsntnde I <br /> MIN SEC <br /> LOCATION <br /> SKETC11 �CTII ITY (�) <br /> IO <br /> _ NEW WELL <br /> 6 a.S C <br /> QMODIFIDATIONIREPAIR <br /> i4qSSI r144, _ Deepen <br /> L S i C _ Other(Specityl <br /> 3 8 J n SI a" <br /> DESTROY/Descnde <br /> Cofe,4 Sj Procedures and Marerla)5 <br /> 1 t% Under GEOLOGIC LOG} <br /> PLV\\ED LSLS (z:.) <br /> `76 Z I 5lh -C <br /> % WATER SUPPLY <br /> V Domestrc Putihr& <br /> ' Irnoahon Industrial <br /> !J H <br /> 4 MONITORING <br /> Uj <br /> r I U TEST WELL <br /> I I I CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> i F DIRECT PUSH_ <br /> INJECTION <br /> t i FVAPOR EXTRACTION <br /> t SPARGING <br /> SOUTH REMEDIATION <br /> Illrnhrr7r nr )A No t Ibr Owalo t of 11 e Il b ale Road% dutlrlut_s <br /> Ftuttt Rlte n (f( ruul ntf(r(!t(I map t x nrld+hwurl palm rf OTHER(SPECIFY) <br /> nt a wml PLEASE BE ACCURATE&(0%IPLETE <br /> I r <br /> 1VATER LE%EL & YIELD OF COMPLETED HELL <br /> zs.Tb <br /> DEPTH TO FIRST WATER (FI! BELOW SURFACE <br /> I I <br /> i r DEPTH OF STATIC <br /> WATER LEVEL �+I�(R)8 DATE MEASURED if 2O <br /> �7 ESTIMATED YIELD (GPM) 8 TEST TYPE <br /> TOI 1L DEPTH OF 1101M �b+Z Frrt TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ftj <br /> TOTIL DEPTH OF COMPLETED "ELL �{Fee1I "AlavtiorbeTepterentantrof n-�cllslmlq-rr7m,weld <br /> DEPTH CVSING (S) DEPTH ANNULAR iIVTERIVL <br /> FROM SURFACE BORE- <br /> HOLE TYPE( L) FROM SURFACE TYPE <br /> DIA x w O a MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) z Mr a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> F! to Ft gm c¢i �a (Inches) THICKNESS (inches) Ft to Ft (TYPE)SIZE) <br /> m oLL (=) (�1 <br /> D 6 8 v V Z D 0 r <br /> q ✓ 1 PVC- Z5ck qO 0.020 SS ; 62 ✓ <br /> 62 ;76 1�_ <br /> r <br /> I I <br /> I I <br /> ATTVCIIY[E\TS CERTIFICATION STATENIE\T <br /> -_._ Geobgic Log <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> �I l <br /> _ Well Construction Diagram NAME �, �(PERSDN FIRM OR CORPORA <br /> //TI <br /> '++ON} (TYPED OR PATEDp � ���(� � /i d �y <br /> Geophysical Log(s) 6 C_ ,, QCrC C( XA [�Ir i ` 157 <br /> Sod/Water Chemical Analyses I <br /> Other ADDRESS Y �T STATE ZIP I <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Siansdlz� 9L21 7V V ? 1-7 L5'1 O I <br /> WELL DRILLERIAUTHORIZED RE ATIVE DATE SIGNED C o7 LICENSE NUMBER <br /> rni rt I5� Ht t t I<r IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />