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ORIGINAL STATE OF CALIFORNIAWR USE ONLY — 00 NOT FILL IN <br /> File with DWR *ELL COMPLETION REPO <br /> Page-1—Of—I— 1 2 r Refer to Instruction Pamphlet STATE WELL N0./STATION NO. <br /> O,vnees Well No. +✓S No. 0941114 1i <br /> Date Work Began Io 3' 07 Ended 1013110 LATITUDE LONGI7UpE <br /> Local Permit Agen AA. , t�n N`. fc HGt� I I I I I I I I I I I I I <br /> Permit No. U5 Z3sfi- permit Date t Zy 6)7 APN/TRS/OTHER <br /> GEOLOGIC LOG -WELL OWNER <br /> ORIENTATION (�) VERTICAL HORIZONTAL _ANGLE —(SPECIFY) Name_"tA11ey'1 ,�.,,6 CCi <br /> DRILLING I/.7/. - s'/_- �ewFLUID Mailing AddreS3q �{} <br /> METHOD �[Q'!IV T�"'� I-_- rn �y' r <br /> DEPTH FROM � Ila u <br /> SURFACE DESCRIPTION �hA. � ICLKsI.. + O <br /> Describe material, grain .size, color, etc. TATE ZIP C1T4 S <br /> FI. to FL <br /> �yyA <br /> L <br /> Address <br /> led t <br /> G City c k h <br /> I I County -.l <br /> s// -'.✓ APN Book 10-_Page I Parcel 061 <br /> S Nom. ✓'. Tow !D� Range Section <br /> Lal <br /> Long <br /> I DEG. MIN. SEC. pEG. MIN. SEC. <br /> Z, Z] LOCATION SKETCH ACTIVITY (4) <br /> ej • '� NORTH �C <br /> NEW WELL <br /> 4 <br /> ` MODIFICATION/REPAIR <br /> I \ _ Deepen <br /> 3'7 — Other(Specify) <br /> 7i I Z DESTROY(Describe <br /> All Procedures and Material <br /> Under"GEOLOGIC LOG <br /> l <br /> /tT 1 / USES(zL) <br /> t. C • "wr1 / WATER SUPPLY <br /> I — DomeallC _ Public <br /> m <br /> k Y� F — Irrigation _ Industrit <br /> 3 a 3 Sr:kA�* - MONITORING <br /> TEST WELL_ <br /> I I t CATHODIC PROTECTION <br /> 1 <br /> HEAT EXCHANGE <br /> I DIRECT PUSH_ <br /> INJECTION <br /> I VAPOR EXTRACTION <br /> SPARGING_ <br /> I SOUTH REMEDIATION <br /> Rlustmte or Describe Distance of Wellfmm Roads,Budding <br /> I Fences,Riven,etc.and attach a may Use additional paper OTHER(SPECIFY)_ <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> I WATER LEVE�(L & YIELD OF COMPLETED WELL <br /> I DEPTH TO FIRST WATER (J�(Ft.)BELOW SURFACE <br /> I DEPTH OF STA Tt�! / 'N <br /> I I WATER LEVEL �-O (Ft.)3 DATE MEASURED '•da- tP I W en <br /> TOTAL DEPTH OF BORINGESTIMATED YIELD' (GPM)S TEST TYPE <br /> (Feet TEST LENGTH (Hre)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 3 (Feet) May not be reprarmatiae of a well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE Tt'PE(-') FROM SURFACE TYPE <br /> DIA. w ii n MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN. <br /> Ft. to F[. (Inches) ou a- GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> (Inches) THICKNESS (Inches) Ft. to Ft. ) (TYPE/SIZE) <br /> O V 'OR Sl N. lit0 -J <br /> *A'. HD ZZ. <br /> 3 ✓ V 2 kw. Lid 0.0w 26 D 3 SF <br /> 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 �^��/N+J� <br /> — Well Construction Diagram NAME- C/ jv 2 Iti/L C-1 N <br /> Geophysical Log(s) IPERSON, FIFIRM, DR CORPORATIDX)�7(TYPED DR PRINTED) l p <br /> SoiUWater Chemical Analyses /[ I U&-a /C, n 'C YO U IS '��- (I �. / Vf 7/ <br /> _ Other ADDRESS _ ,-,,—,Q ,�� �� in TATE ZIP <br /> C <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed ✓`�- 1 2 P G 7 )100'2 / <br /> C-57 LICENSED WA TE ELL CONTRACTOR iilWIRSE NUMBER <br /> DWR 183 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FO SP 03 7883 <br />