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DUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> Drlller's Cop WELL COMPLETION REPORT <br /> Page_L of Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Nell Na No 749401 El <br /> c� Q LATITUDE LONGITUDE <br /> Date Work Began 5-01 End d� <br /> • Local Permit Aj�lenc U' APNITRS/OTHER <br /> Permit No Permit DateW$ O <br /> GEOLOGIC LOG L WNER 5``r{�� � �L� <br /> ORIENTATION ( ! ) VERT CAL _HORIZONTAL _...^ANGLE _{SPECIFY) N aTt')e~ h'� _ <br /> METHOD+1 t f'�+ /s� `Ci`i 1 n � )"FLUID :lV� ltilg �ld}CSS 64 V J� <br /> DEF URFACEM DESCR PTION ' <br /> Ft to Ft Describe material grain Size color, etc�� ��� cl�$.'� � � � � 3 STATE ZIP <br /> ELL ATIO <br /> ISee tlrir it.)j 4,11, It <br /> Coui QrJj C�la Jr Ni ' <br /> f �AP�N Book Page Parcel <br /> I I N Township Range Section <br /> I NORTH Longitude r <br /> ' WEST <br /> I <br /> � •�� �,.� DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH 9R"fIVITY (2L) <br /> NORTH l_/ NEW WELL <br /> �{ MODIFICATION/REPAIR <br /> 5,r ult iR — Deeper <br /> Other(Specify) <br /> I f I.,. �� ;' ✓� DESTROY(Describe <br /> Proce <br /> Under duGEOLOGIC LOG) <br /> PLANNED USES (�} <br /> WATER SUPPLY <br /> w <br /> Domestic Public <br /> Irrigation _ Industrial <br /> I I W w MONITORING <br /> i I TEST WELL_ <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE— <br /> I I <br /> 61REC7 PUSH <br /> I I INJECTION _ <br /> i I VAPOR EXTRACTION <br /> I I SPARGTNG <br /> SOUTH REMEDIATION <br /> Illustrate or Descnbe Dtrtance of Well firom Roads Buildings <br /> I I Fences Rmers etc and attach a ntap Use additional paper <br /> � OTHER(SPECIFY)necessary PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <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 well's long-term yteld <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE TYPE <br /> DIA r a MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> (Inches) z w a GRADE DIAMETER OR WALL IF ANY MENT TOWTE FILL <br /> Ft to Ft m opo LL (triches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> 5 LA <br /> I f <br /> I I� <br /> I <br /> I I <br /> I I <br /> FTACIIMENTS CERTIFICATION STATEMENT <br /> I the unders gned certify that this r art Is complete and accurate to the best of my knowledge and belief <br /> {�6eolog}c Log �j�j ter' r1t� <br /> 1X Well Construction Diagram NAME'+e FAV!}10 SV J { <br /> + (PERSON FIRM OR Pd <br /> PO TION) (TYPED OR PRIMED)r a f j r� <br /> Geophysical Log(s) 3 Cy � .3v�> 554) 6� � l ( l ! f1 z <br /> oil/Water Cheml al Analyses <br /> Other - 14AA ADDRESSrn CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION !F 1T EXISTS Signed <br /> LL DRILLERIAUTHORIZ REPRESENTATIVE DATE SIGNED C 51 L#CENSE NUMBER <br /> DN%Ii ISS HEV 1197 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />