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DUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL !N <br /> Driller's Cop WELL COMPLETION REPORT 11111111111 <br /> Page—L., Refer to Instruction Pamphlet STATE WELL NO!STATION NO <br /> Owner's Wel, 1Vo _ t� No 749402 F <br /> Date Work Began I B I; End d 1- <br /> LA74TUDE LONGITUDE <br /> Local Pet mit Agency <br /> G IS 0 <br /> Permit Nlb v Permit Date — APNITRSIOTHER <br /> GEOLOGIC LOG f � O NER <br /> ORIENTATION (Y} VERTICAL fes-HORIZONTAL _ANGLE 1 lSPECIFY) Name <br /> DEPTH FROM DRiLL1NG t[ L ., „ j+r r'FLUID ,Mailin Ad�i'eSS E I r <br /> METHOD @P" ff k k <br /> SURFACE D SCR! TON F STATE ZIP <br /> Ft 10Ft ,Describe material grain size color, etc WELL OGAT <br /> -� Address <br /> County <br /> 11p fl 51,hr jruLr �APN Book Page Parcel <br /> Township Range Section <br /> I I Longitude t I <br /> 'tLatitude NORTH WEST <br /> ,!1 " DEG MEN SEC DEG MIN SEG <br /> LOCATION SKETCHTIVITY (�) <br /> NORTH NEW WELL <br /> B <br /> MODIFICATIONIR EPAIR <br /> l 1 f "44•'"�`r. '�'�. r V fln� Deepen <br /> ayo 4:s,� ((('w+n _,,,— Other{Specify) <br /> s I t <br /> y ff DESTROY(Describe <br /> ProceI 1 I .h •,,_,__.� erials <br /> Unde�aGEOLOGICres and rLOG I <br /> % �+ PLANNED USES (_�0 <br /> WATER SUPPLY <br /> Domestic — Public <br /> I I Irrigation _ Industrl <br /> I I W ¢ MONITORING <br /> LU <br /> i TEST WELL <br /> r I Y CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH— <br /> ' ' INJECTION <br /> I I VAPOR EXTRACTION <br /> I I SPARGING— <br /> I ISOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads Buildings <br /> i I Fences Rmam etc and attach a map Use adchhonal paper if 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 1 <br /> DEPTH OF STATIC <br /> WATER LEVEL (Fl)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING I {Feet} TEST LENGTH (Hra)TOTAL DRAWDOWN (Ft} <br /> TOTAL DEPTH OF COMPLETED WELL -5-1-(Feet) "May not be representative of a well's long-term yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(�) <br /> DIA Y w C.o a MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> (Inches) = w Zr r; GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL ITER PAC <br /> Ft to Ft o (Inches) THICKNESS (Inches) Ft to Ft ( ) <br /> V L t <br /> iA r I <br /> I <br /> I I <br /> ATTACHMENTS CERTIG.FICATION STATEMENT <br /> I the undersl ed,certify that this r p rt Is complete an accurate to the best of my knowledge and belief <br /> • — �dologic Log <br /> Well Construction Diagram NAME t <br /> ( SON FIRM ORORP RATION) (TYPED OR PRINTERS t <br /> Geophysical Log(s) r ; 510 ��Aq P fi� <br /> 65 <br /> oil/Water Chemical Analyses JJ <br /> 01her --1F;--4'"� ADORES STATE ZIP <br /> ATTACH ADO1710NAL fNFORMAT1dN !F!T EXISTS Signe �� <br /> WELL ORILLERIAUTHD D R PRESENTATIV£ DATES NED C 57 LICENSE NUMBER <br /> nr�x IIB x>� It sr IF ADD710NAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />