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DUPLICATE STATE OF CALIFORNIADWR USE ONLY - DO NOT FILL IN <br /> D-flier's Copy WELL COMPLETION REPORT <br /> Page I of t Refer to instruction Pamphlat STATE WELL NO/STATION NO <br /> Owner's Well No W`L No 762542 LATITUDE ❑ LONGITUDE ❑ <br /> Date Work Began - t Ended -I " <br /> Local Permit Agency L APNITRSlOTHER <br /> Permit NoU Pe mit Date - <br /> GEOLOGIC LOG —'m LL OWNER <br /> ORIENTATION (2!L) � r <br /> VERY HORIZONTAL _ANGLE (SPECIFY) Name <br /> DRILLING f 7.rj I CLA I�`}tv VA ","s <br /> )1 k�?� <br /> METHOD j �I FLUID ` Mal rig�Addre55 <br /> DEPTH FROM tiler .ti .I � <br /> SURFACE DESCRIPTCON r <br /> Describe inatertal rain size color etc <br /> �\ ITY 1 STATE YIP <br /> D <br /> Ft to Ft g <br /> WEL LOCA N <br /> ' Address 1 I4r <br /> I G, S Cori �7 nrr4vvj sL1 1. <br /> / r PN Book / Page Parcel <br /> Township Range Section <br /> I \ �. �+� i 'Latitude t I NORTH Longitude I I WEST <br /> DEG MIN SEC DEG MIN SEC <br /> L \ \ LOCATION SKETCH /f�TIVITY (:) <br /> NORTH 6—� NEW WELL <br /> i o <br /> MODIFICATIONIREPAIR <br /> - Deepen <br /> \ l}' — Other(Speedy) <br /> I i I v <br /> DESTROY(Describe <br /> Proceres and <br /> i I ,4,4__w..•f ` <br /> duUnderGEOLOGICtLOG) <br /> PLANNED USES (2f) <br /> WATER SUPPLY <br /> Domestic Puhllc <br /> I i Irngallon Indust <br /> � r <br /> I I W ¢ MONITORING <br /> i I TEST WELL— <br /> . I I CATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH— <br /> I I INJECTION.�,.. <br /> I V VAPOR EXTRACTION <br /> I I SPARGING- <br /> I ISOUTH REMEDIATION- <br /> Illustrate or Describe Distance of Well from Roads Burfd:ngs <br /> Fences Rivers etc and attach a map se ndolihonal ppaper t OTHER(SPECIFY)— <br /> necessary PLEASE BE ACCORATE&COMPLETE <br /> I I WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I i <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) &TEST TYPE — .. <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 wells long-term yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE � FROM SURFACE TYPE <br /> FROM SURFACE HOLE J;E� <br /> (—} <br /> DIAp d MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> (Inches) a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to Ft 0 (inches) THICKNESS (Inches) Ft to Ft (� (� (TYPEISIZE) <br /> LLL ) (—� <br /> tloz u 52 <br /> I <br /> I I <br /> I I I <br /> TTACHNIENTS CERTIFICATION STATEMENT <br /> I the undersigned certify that this re ort Is complete and accurate to the best of my knowledge and belief <br /> /�reologlc Log t/,' I <br /> Well Const action Diagram NAME00 3 .. I " ;� <br /> (PER SO FIRM OR DO RATION) (TYPED OR PRINTED) <br /> Geophysical Log(S) r <br /> SoilNVater Chem1 al Analyses t ! I <br /> ADDRESS 4 {l { CITY STATE ZIP <br /> -Other��Lf 1 11 G!'Vt Signed l� 1 �t � 11 r Wf �! Ltiu��� �- � � ���17,3 <br /> ATTACH ADDITIONAL 1NFORMATfON fF IT EXISTS ELL DRILLERAUTHON201 REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> nnx lar, REt 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />