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DUPLICATE STATE OF CALIFORNIA DWR USE ONLY DO NOT FILL IN <br /> Driller's Copyy WELL COMPLETION REPORT <br /> F STATE WELL NO/STATION NO <br /> Page�O{, f Refer to Instruction Pamphlet <br /> Owner's Well No _ —5 � "° 749400 LATITUDE ❑ El <br /> Date Work Began �"��—�( Ended <br /> Local Permit A e S + 11() aPNrTRsroT1 <br /> Permit No f! -Permit Date�'jy_ol- Z <br /> GEOLOGIC LOG Ai' <br /> s, VSyrEL OWNE,R <br /> +� / i 'P` <br /> ORIENTATION (✓) _VERTICAL HORIZONTAL —ANGLE SPECIFY) Name � ` <br /> DRILLING q t +' # 0 <br /> METHODA ( EM n 'tr+1Y� hFLUID . Ma31a Addy t / <br /> DEPTH FROM Z <br /> SURFACE DESC IPTION ` , c€ry S STATE zip <br /> Ft to Ft Describe material, grain size color etc �� .��,/'! r, <br /> T.L LOC TIQ� <br /> + / Gity <br /> A)'�Bok <br /> ' Page Parcel <br /> TawnsliTp; Range Section <br /> Latit"Llde I 1 NORTH Longitude € I WEST <br /> DEG MIN SEC DEG MIN SSC <br /> LOCATNORTH ETCH Z IONWELL IT ( ) <br /> A r ~*`'`•. 4 i•� �• � � ( `i �� MODIFICATIONIREPAIR <br /> - Deepen <br /> - Other(Spicily) <br /> f ✓ J <br /> — DESTROY{Describe <br /> Procedures <br /> 1WS <br /> UnderGEOLOGICCrOG) <br /> 1 1 f i PLANNED USES (:) <br /> WATER SUPPLY <br /> Domestic Public <br /> 1 _ Irrigation .� Industrial <br /> i 1 co <br /> L MONITORING— <br /> i i TEST WELL— <br /> CATHODIC PROTECTION <br /> • t i HEAT EXCHANGE <br /> DIRECT PUSH <br /> I I INJECTION <br /> 1 1 VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> 111ustmte or Describe Distance of Welf front Roads Buildings <br /> Fences Rr,.'m etc and attach a map Use additional paper t OTHER(SPECIFY) _ <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC <br /> WATER LEVEL (R)&DATE MEASURED <br /> I <br /> ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING V410 Feet) TEST LENGTH (Hrs) TOTAL. DRAWDOWN_(Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE(:: ) FROM SURFACE TYPE <br /> DIA Y MATERIAL I INTERNAL GAUGE SLOT SIZE CE BENFILTER PACK <br /> Ft to Ft (Inches) U1�-1 D J GRADE bIAMhes) H WALL IF ANY C NESS {riches Ft to Ft MENT <br /> �TONITE FI!L (TYPE/SIZE) <br /> cc U) o ) <br /> 5 `S V b•� =� ' �f <br /> I _1 <br /> I <br /> I 1 <br /> I i <br /> TACHMENTS (.�L) CERTIFICATION STATEMENT <br /> I the unders gf1kned, certify that this r p I Is complete and accurate to the best of my knowledge and belief <br /> J�aeologlc Log � <br /> W811 Construction Diagram NAME t r� u <br /> RSON FIRM OR CORPOR ION) (TYPED OR PRINTED) <br /> Geophysical Log(s) �N1 ,, �i�f t n� 0 f, f� C4 95E <br /> o1Allater Chemical Analyses W (�4 MAIM j <br /> { ADDRESS 1 STATE sZZIIP <br /> Other AU ,r � / }! / v —f dj 1 5 � 1t] <br /> A77AG1'!ADDITIONAL lNFOAMATlON 1F!T EX15T5 S'gae f � ) 1� r' l� d I A ` y( <br /> WELL DRILLERIADTHORIZ REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> Dt�R 188 R]Ev I1 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />