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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT ) 1 I I <br /> Pave I of Refer to Instruction Pamphlet STAT= WE" NO-'STATION NO <br /> OK-ner's Well No ��^,tv- ` No 0932162 i <br /> Date Work Began 1-16__'p Endedrc+S LATITUDE LONGITUDE <br /> OCal PenTut AQencv i-VIA r�c/V t�'� C_U La G+tu 11,�r7 t�t3�lf�!G l lock f�c� , APNI,I a I Hey <br /> Pennit No Ln D�5 1�9 Permit Date j7_—S?—v:5 <br /> J GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) V VERTICAL _HOR17ONTA� —ANGLE —(SPECIFY) Name 1 '• r i ` <br /> METHOD �f ti T(•" ' ' FLUID I'talll Addr"' <br /> DePTH�tEoM <br /> SERFAGCA <br /> DESCRIPTION ' <br /> Ft to FL Describe material grain size color etc crrY y` STATE f ZIP <br /> "� WELL L C <br /> TION <br /> ' Address C v <br /> 'rPCC- city-:-- r <br /> -}� <br /> rl&eA Av �� County' i.;i ).)IFt J r'1 <br /> APN Book ;kcl Page 00 -Parcel <br /> Township Range Section <br /> L at I ! N Long� ! I -- W <br /> DEG MIN SEC o DEG MIN SEC <br /> ✓ LOCATION SKETCH AC, IVITY (4) <br /> I , i! e ' ,r•f �- NORTH ✓NEW WELL <br /> r` 4 <br /> MODiFiCATIONIREPAIR <br /> — Deepen <br /> IjL tV � _ Other(Specify) <br /> I I , <br /> f' x <br /> _ DESTROY(Describe <br /> Procedures UnderGEOLOGICLOG <br /> USES ( ) <br /> WATER SUPPLY <br /> Domeslic Public <br /> Irrigation Industnal <br /> I I MONITORING <br /> LU i t TEST WELL <br /> I CATHODIC PROTECTION — <br /> HEAT EXCHANGE <br /> I c <br /> DIRECT PUSH <br /> ' INJECTION <br /> + I VAPOR EXTRACTION <br /> SPARGING <br /> ! i SOUTH REMEDIATION <br /> Illustrate or Descnbe Distance of Well from Roans Buildings OTHER(SPECIFY <br /> Fences Rmers etc and attach a map Use additional paper; ) <br /> necessanl PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> i DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE:MEASURED <br /> I I ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING I G (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELLt V5 (Feet) "May not he representative of a well's long-terns yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE('') <br /> DIA Y z rr n. MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) g zo� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to F1 m o w (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> �/ ' 1✓ V�- 4 J`! ' <br /> I t OL"'t'.Y& 0'b 7 <br /> 1z <br /> I 5 <br /> I i <br /> A —ACHVIENTS (t) CERTIFICATION STATEMENT <br /> I, the undersigned, certify that this repo IS complete and accurate to the best of my knowledge and belief <br /> eologlc Log <br /> Well Construction Diagram NAME � j(�, d'1V1 r'J.Y m + <br /> (PERSON FIRM OR CORPORTne <br /> A Nl ITYPEO OR PRINTED) <br /> _ Geophysical Log(s) �t ✓s /l n ` o <br /> $odANater Chemical Analyses f r <br /> 1 Other 1 �14✓✓1 ADDRESS CITY STATE ZIP <br /> / <br /> ATTACH ADDITIONAL INFORMATION IF f7 EXISTS Signed �' C <br /> C 57 LICENSED WATER W LL CONT ACTOR DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 05 G3 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM r� OSP 03 78836 <br />