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DUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> Drlller's Cop WELL COMPLETION REPORT <br /> WELL NOISTATION NO <br /> Page�of ��} Refer to Instrtactevn Pamphlet STATE WE❑1 111 ❑ <br /> Owne>'s Well No "" — No 762541 <br /> Date Work Began 13—12 EndedLATITUDE LONGITUDE <br /> . Vocal Perinit e y A �v►Joe4 v vk (_o v� 11 0 D <br /> Permit Perin <br /> 91 P rmit Date !)— APNIfRS/OTHER <br /> GEOLOGIC LOG !\ ,``E L OWNER <br /> ORIENTATION (✓} EILLI <br /> ERTI,AL HORIZOONTAL ___._ANGLE _(SPECIFY) Name` ( rr T01,141 <br /> � t i' .- rn <br /> DF <br /> D�Pll <br /> METHODAI t'rYoh, CC!51'5} �t�F UID IWV f 1VIaiILn ,AddreSS 1}0 � <br /> D SCRI ION, % iA`'fl! L ~ice "' � 4 �??Describe material rain size Color, etc� CITYf STATE �P <br /> g "•> � `` L� WELL OCAT��p'''� �t <br /> I .AadAss J 1�� q��r' CA I<r7 _ <br /> 11 1 <br /> � a �� '( '� �APN Book Page-Parcel <br /> ^�"�'? \{ �55� Township'" ' Range Section <br /> i I M /lel "•7./; \ 1r \ NORTH WEST <br /> Latitude i - � _ _ Longitude I I <br /> DEG MIN SEG DEG MIN SEC <br /> 1 " LOCATION SKETCH TIVITY (�) <br /> f�`S <br /> NORTH �w � Y NEW WELL <br /> 1 G <br /> E ' r^ �� '1 �� �CA`✓t��./"`fJ (/d'h 1 �f MODIFECATIONlR5PA4R <br /> ' I ✓ ���� ''�. �' .. r J a y _ Deepen <br /> r a \ — Other(Specify) <br /> DESTROY(Describe <br /> Procedres and Materials <br /> Under UGEOLOG CLOG) <br /> ' !1 PLANNED USES (�) <br /> WATER SUPPLY <br /> Domestic - Pub4c <br /> I <br /> k„ Irrigation Industrial <br /> M <br /> LU <br /> W MONITORIN - <br /> I I y TEST WELL- <br /> t <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE— <br /> I DIRECT PUSH— <br /> INJECTION— <br /> ' ' VAPOR EXTRACTION <br /> I i ` SPARGING— <br /> I I SOUTH REMEDIATION— <br /> I11Mtrate or Descnbe Distance of Well from Roads Bulldengs <br /> Fences Rivers etc and attach a map Use additional paper OTHER(SPECIFY)- <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC , <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> t <br /> I ESTIMATED YIELD (GPM) & TEST TYPik,, <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL .DEPTH OF COMPLETED WELL _..._.(Feet) "May not be representative of a well's long-term yzeld <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE('} FROM SURFACE TYPE <br /> HOLE <br /> DiA x Z a MATERIAL I INTERNAL GAUGE SLOT SIZE CE BE <br /> {Inches) z w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m 0 �� (Inches) THICKNESS (Inches) Ft to Ft (TYPEJSIZE} <br /> I, V( t)� <br /> I <br /> I i <br /> I I <br /> TACHNIENTS (:) CERTIFICATION STATEMENT <br /> Log <br /> I the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geologic <br /> Well Construction Diagram NAME ` P1I<ttoAplew f _- <br /> Geophysfcai Log(s) (PERSDN FIRM R COR RATIONI ( PEO 11 PRINTED) <br /> od(Water Chemical Analyses <br /> Ifk ADDRESS ,�j //��'' //,��� / CITY STATE ZIP <br /> omer Sr�neu)U "" s'"' 1 7 U��S 1+, t ,} `E <br /> ATTACH APDlTlONAL INFORMATION IF ITEXISTS WELL DRILI REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> DnR lhS RF\r 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />