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DUPLICATE STATE OF CALIFORNIA DwR USE ONLY — DO NOT FILL IN <br /> Drilfet's Copy WELL COMPLETION REPORT <br /> Page 1 4f [tJ {, Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well NO �{VV�""' ---.- _ NO 762540 LATITUQE 11LONGITUDE 11Date Work Began I',),_L)I Ende <br /> d �� l -� <br /> Local Permit Agency Sa na+ZG�� tn�+3 � f - APN/TRsrarl <br /> • HER <br /> Permit No Permit Date ^ <br /> GEOLOGIC LOG ^. LL PWNER <br /> ORIENTATION (✓ ) VERTICAL —HORIZONTAL ANGLE —{SPECIFY) NameDRILLING <br /> METHOD] k ' +^'!t�FLtJID(✓1•t��T -M ing <br /> Address _ <br /> DEPTH FROI ./j ,�" <br /> SURFACEM DESCR PTION `t ` .ru l ~ { <br /> Ft to Ft Describe material grain size color, etc��� � C��C � STATE ZIP <br /> , \ I I—WELL OCATLq <br /> Address 1 <br /> — <br /> II , APN Book l age Parcel <br /> �Towriship Range Section <br /> ° t i J 4 i ' •r t Lafstude NORTH Longitude t I wesT <br /> DEG MIN SEC DEG MIN SEC <br /> t £ i r ' ,� LOCATION SKETCH ✓ NEw wEx { } <br /> t NORTH <br /> MODIFICATIONIREPAIR <br /> — Deepen <br /> _ Other(Speclty) <br /> i f lam-. DESTROY(Describe <br /> Proce <br /> erials <br /> Ude duGEOLOGIC res and rLOG) <br /> �'3 I PLANNED USES (�) <br /> I ^I, <br /> WATER SUPPLY <br /> Domestic — Public <br /> — <br /> Irrigation Indus al <br /> I I Lu 4 MOMTORING- <br /> Lu <br /> i TEST WELL- <br /> CATHODIC PROTECTION- <br /> t I HEAT EXCHANGE- <br /> I I DIRECT PUSH <br /> INJECTION- <br /> 5 VAPOR EXTRACTION- <br /> i I SPARGING- <br /> ' I SOUTH REMEDIATION- <br /> Illustrate nr Describe Distance of Well from Roads Butldtngs} <br /> i Fences Rivers etc and attach a trap Use ruldttionnl paper 1 OTHER(SPECIFY) <br /> necessanj PLEASE BE ACCURATE&COMPLETE <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> I WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORING Fest) TEST LENGTH (Hrs)TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield <br /> DEPTH SORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE TYPE <br /> DIA Y IZ17, n MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> (Inches) w r a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to Ft In c�i o - {Inches) THICKNESS (inches) Ft to Ft (� (� ) �) (TYPE/SIZE) <br /> w <br /> V L. <br /> F t r <br /> = I <br /> TTACHMENTS (t) CERTIFICATION STATEMENT --- <br /> I, the undersigned certify that this report Is c mplete and accurate to the best of my knowledge and belief <br /> Geologic Log <br /> Well Construction Diagram NAME 111 t <br /> (PERSCIN FIM OR CORPORATION) (TYPE OR PRINTEDI n <br /> — Geophysical Log(s) 1 r <br /> Soil/Water{Chemical Analyses <br /> Other �'}� "N� ADDRESS ((CITY tt (� STATE ZIP <br /> ATTACH ADDI'TioNAL 1NFORMgTlON IF IT EXISTS Srgne7 r l� � Ir 11 tlr(r4)5�� <br /> 'SHELL DRtLLERAUTHOREED REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> DMR ISS RE', I) s7 IF ADDITIONAL SPACE 13 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />