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I <br /> DUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> Driller's Copy WELL COMPLETION REPORT <br /> jj STATE WELL NO/STATION NO <br /> Page Of-!— Refer to Instruction Pamphlet ❑ ❑ <br /> Owner's WeII No �� No <br /> 762544 <br /> Date Work Began B Ended LATITUDE LONGITUDE <br /> Locf,al 1'ermrtAgency A APNlTRSlOTWER <br /> Permit No ??!q j j Permit Date — <br /> GEOLOGIC LOG f � L OWNER <br /> ORIENTATION (�) VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Name � `�;1` <br /> DRILLIN 'Al "ILA �Ip� " ` \ - <br /> DEPTH FROM METHO + FLUID1 �I Ma11 Address { <br /> 1 w <br /> SURFACE DESdRIPTION .\/" \ ` <br /> Ft to Ft De5Crn17¢ maternal gran size COZOr etc �� ``> c�'1�,0�0 ` TATE ZIP <br /> WELL CAT <br /> -,'-.Address f' <br /> Tv G A i - > <br /> PSN Book ` Fage Parcel <br /> Township Range Section <br /> \ 1 V NORTH WEST <br /> %Latrfiude I I Longitude <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH CTIVITY (�) <br /> NORTH NEW WELL <br /> M0OIFICAT4DNIREPAIR <br /> Deepen <br /> v Other(Specify) <br /> I I f <br /> DESTROY(Describe <br /> Procedures and Matenafs <br /> '`-• Under GEOLOGIC LOG I <br /> PLANNED USES (�) <br /> WATER SUPPLY <br /> Domestic Public <br /> Irrigation Ind in <br /> U3 <br /> ' U.1 ¢ MONITORIN <br /> I I TEST WELL <br /> I 7 <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> I I <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGfNG <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of WellfromRoads Buildings <br /> Fences Rmers etc and attach a map Use addlttonal paper£i OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE da COMPLETE <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> I <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 CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE FROM SURFACE <br /> HOLE rypE <br /> DIA x z cc MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN <br /> (inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to F1 m C) cgo LL (fiches) THICKNESS (Inches) Ft to Ft (�} (✓) (�) (TYPE/SIZE) <br /> r <br /> I r <br /> I r <br /> I 1 <br /> TACHMENTS (�) CERTIFICATION STATEMENT <br /> 1, the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> aologic Log <br /> Well Construction blagram NAME E ! �' Vt <br /> (ftEhMN FIk9 OR CDRPORA!DN) (TYPED OR RINTED) <br /> — Geophysical Log(s) 7 � j <br /> oil/Waller Chemical Analyses r <br /> `- �ADDRE { 1 CITY STATE ZIP <br /> Other ; i inn r uRnk J ` r fr � /6 /S 1 11 to <br /> ATTACH ADDIYIONAL INFORMATION IF IT EXISTS <br /> Signe 4" 'f/ 1 t �'� i/ f`rn LLQ SIGNED <br /> _ 57 I t <br /> WELL DRILLE llT ORIZ REPRESENIATIYE r/ DATE SIGNED C 57 LICENSE NUMBER <br /> D1lR 158 81,1' i) s7 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />