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DUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT- FILL IN <br /> Driller's Copy WELL COMPLETION REPORT <br /> Page I - of ! Refer to Instruction Pamphlet STATE WELL NO/STATION NO ` <br /> Owner's Well Not�y4V'❑ kk Nd /� (� /� O ❑ <br /> � J-11-01 <br /> ❑ <br /> Date �oik Began t-0 I dd �-! tq-0� 4 v"t LATITUDE LONGITUDE <br /> Lc&l Permit A ency US S F- "1✓ gPNITRSIOTHER <br /> Pernvt No Perin t Date <br /> GEOLOGIC LOG _` v jf[� �pL V► ER <br /> ORIENTATION (✓) _VERTiRILLINICAL HORIZONTAL ANGLE _ PECIFY) Nam' A <br /> METHOps.{I r I It `I r i }�5`r EFLUID 1yt d/l . ,Ma 1mj Addres 4f•!F { a• ' t�f <br /> DEPTH FROM t i� ,�\ � � <br /> suRFACE DESCRI ION <br /> Ft to Ft Describe matertal groan size color, etc �`� CITY STATE zip <br /> WELL CATI <br /> ,� cam` �C3ou'nty I <br /> ' = � ~ A�N Book -` age Parcel <br /> Toiiship°? Range Section <br /> Latitude I I NORTH Longitude I WEST <br /> DEG MIN SEC DEG MIN SEC <br /> I I �°�.�\` � \•l�ly` LOCATION <br /> OCATtt SfJfKtEf.TaCwH 4' <br /> 0r[VITY <br /> (L) <br /> NORTH / NEW WELL <br /> MODIFSCAPAIRs!6 ' , i. Deepen <br /> I e <br /> 4 .,.,. Other(Specify) <br /> i + \ <br /> iy W I s <br /> DESTROY(Describe <br /> Procedures and Matenafs <br /> Under GEOLOGIC LOG) <br /> PLANNED USES (—`) <br /> WATER SUPPLY <br /> Domestic Pubhc <br /> [ I <br /> F- Irrlgatfon indust <br /> Ca <br /> + i L ¢ MONITORING <br /> I TEST WELL <br /> i CATHODIC PROTECTION_ <br /> HEAT EXCHANGE— <br /> DIRECT PUSH <br /> SNJECTION <br /> I I VAPOR EXTRACTION _ <br /> I i SPARGING- <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Welt from Roads Buddmgs <br /> Fences Rivets etc and attach a ma[ Use additional paper.1 OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I i <br /> f DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i t DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING 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 BORE_ <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(�} <br /> DIA , p a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> (inches) z w z� a GRADE DIAMETER OR WALL IF ANY MENT TONI7E FILL <br /> Ft to Ft m �� (Inches) THICKNESS (Inches) Ft to Ft (TYPEl51ZE} <br /> I -6{{5 ((c It T r r, <br /> 50 45Jivt <br /> I <br /> I I <br /> TTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned certify that this re ort is complete and Pccurate to the best of my knowledge and belief <br /> — Geologic Log n undersigned_ <br /> Well Construction DTagram NAME�•v +� I <br /> Ir LRSDN FIRM OR COR DRA ION} (7YPEO DR TE{) <br /> — Geophysical Log{s} � � � � � <br /> oil/Wa�t�er,Cheri(ical`Analyses <br /> 1,t. ADDRES ` CITY STHTE + ZIP <br /> Other IM <br /> ATTACH AOD1770NAL 1NFORMATfDN tF tT EXISTS SignedWELL DRILLE !AUTHORS D EPRESENTATIVE DATE 54NEDCENSE NUMBER <br /> DWR 14h JIM' 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />