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ORIGINAL ST-ITE OF CALIFORNIA DWR USE ONLY — DD NoT FILL IN <br /> File with DWR WELL COMPLETION REPORT I I I I l <br /> Page—L of I Fiejer 'a Ins`-a Cron Pamphlet STATE WELL NO/STATION NO Owner's R'ell No o r� <br /> ' t � No 0532161 1 1 1 I 11 I <br /> LATITUDE 11::(,y — <br /> � ����� LONGITUDE <br /> Date Work Began L-- 5-L-D Ended r L L )u r I <br /> al Pernut Agency J L v1 c-t S u,✓1 (r-cvw F��v 1 1/12 v{� _ (f Gi til 1 <br /> AP NfTRS OTHER <br /> e=t \p f�jS✓ 55 1 �i"� - �Permit Date 12— "D <br /> GEOLOGIC LOG «ELL OSNNER <br /> ORIENTATION (_') Z VERTICAL —HORIZONTAL —....ANGLE —(SPECIFY) Name <br /> � <br /> VI nDRILLING ho l a+ #de,S <br /> DEPTH FROM METHOD yw� FLUID <br /> i 'f•Z yr 1.Jt <br /> G 22 <br /> SURFACE DESCRI ION L' . <br /> STATE ZIP <br /> FL to FL Describe material grain size color etc CITY <br /> ►ELL WCAXION <br /> �Addre _ <br /> IZU -,n — <br /> kt -5City <br /> i <br /> , I -7 <br /> 1r(. s L ` CouNI <br /> I i ' ,��• - '�` APBook _Page� �..Parcel LY <br /> Township Mange Section <br /> Lat f I N Long w <br /> DEG MLN SEC DEG MIN SEC <br /> LOCATION SKETCH A_ ITY (.i:L) <br /> NORTH NEW WELL <br /> MODIFIGATiONIREPAIR <br /> — Deepen <br /> _ Other(Specify) <br /> I I , <br /> ✓ i <br /> .r"rIT x pESTROY(Describe <br /> / a Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> it USES (.�L) <br /> WATER SUPPLY <br /> Domestic Public <br /> I I trrlgauon Industrial <br /> I I LLI ¢ MONITORING <br /> TEST WELL_ <br /> I <br /> CATHODIC PROTECTSDN <br /> HEAT EXCHANGE <br /> I I DIRECT PUSH <br /> INJECTION <br /> I t VAPOR EXTRACTION_ <br /> SPARGING — <br /> I I REMEDfATIgN <br /> Illustrate or Describe Distance of Well from Roads Buildings <br /> OTHER(SPECIFY) _ <br /> Fences letters etc and attach a map Use additional ppaper <br /> necessary PLEASE BE ACCURATE&COMFLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I , <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> I I WATER LEVEL (Ft)&DATE MEASURED <br /> I ESTIMATED YIELD ' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (,Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPIH OF COMPLETED BELL (Feet} *May not be repres-entatme of a well;long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE TYPE( ') FROM SURFACE TYPE <br /> HALE w INTERNAL GAUGE SLOT SIZE CE BEN <br /> DIA Y w 0 11 MATERIAL I FILTER PACK <br /> (Inches) 2� E: GRADE DIAMETER OR WALL IF ANY MENT TONITEFIL Pf=/SIZE <br /> Ft to FL ¢ o0 Ft to Ft QTY ) <br /> m �_ (inches) THICKNESS (Inches) ( } ( ,F) <br /> w � <br /> 9 r7 1/ r�C I,Vr(; q 71 -75 <br /> -7`5.. : zI Z <br /> I <br /> k 5� <br /> I I <br /> ATTACHMENTS ( t ) CERTIFICATION STATEMENT <br /> / I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> AfGeologlc Log r,J [' t <br /> Well Construction Diagram NAME L� <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) ^^i7 y p � cm Z <br /> I/SOIIIWater CherniCal Analyses J� } �L + "ft �lL 7 CITY STATE ZIP <br /> OtheT i�J�6,nADDRESS <br /> ATTACH ADDITIONAL INFORMATION 1F IT EXISTS Srgned WATER WE CONTRACTOR DATE SIGNED C 57 LICENSE MBER <br /> C 5] LICENSED <br /> DtiVR 188 REV 05-113 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 7883s <br />