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ORIGINAL STATE OF CALIFORNIA. DWR USE ONLY — DO NOT FILL IN <br /> File with DWR <br /> WELL COMPLETION REPORT F ) I I I I I I I <br /> Page 1 a Refer to Instruction Parnvhlet STATE WELL NO 'STATION NO <br /> Owner's �`ell No � �- �j No 0932163 I <br /> Date -Work Bevan_17-1` -4ZS Ended ��� `Q LATITUDE LONGITUDE <br /> cal Permit AQen/�c� L� 2 L"1541, <br /> A "` r,, <br /> Permit IVO 2In, o -1 5 I e r Permit Date� !-"�y-1'� APN/TRS,0THER <br /> GEOLOGIC LOG «ELL O"NER <br /> ORIENTATION <br /> (=) _ZVERTICAL —HORIZONTAL —ANGLE _(SPECIFY) A eine R I <br /> DEPTH FROM METHOD :l :-�(.% `t FLUID Nfaili31g -address ot• D, <br /> SURFACE DESCCRI�ION <br /> Ft to Ft Descnbe material grain size color etc T STATE ZIP`�- <br /> WELL Lf3C IO\ <br /> Address G 7 <br /> ' V �Gs i <br /> •� � Ctly I r t C:,j <br /> ^ T F { ! ''" COL1Llt,-, JLry\ ..�f���L r>>4 <br /> a <br /> AFN Book Page 1 -'0 Parcel --- <br /> ' Tom nshtp Range Section <br /> Lit I I N Lona I I W <br /> i r ,! �� h ✓ --_- DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH si�,�h'ITY ('') <br /> NORTH /NEW WELL <br /> ,a 3i p MCCIFICATIONlREPAIR <br /> :5, — Deepen <br /> _ Other(Specify) <br /> DESTROY(Describe <br /> I � �rld ✓ � J ` _ <br /> Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> USES { ) <br /> WATER SUPPLY <br /> I Domestic Public <br /> � )rogation �. Industrial <br /> � r <br /> uj <br /> < MONITORING <br /> TEST WELL , <br /> I I CATHODIC PROTECTION <br /> I i <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> I <br /> INJECTION <br /> t VAPOR EXTRACTION <br /> SPARGING <br /> r SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads Buildings <br /> Fences Raters etc and attach a map Use additional paper t OTHER(SPECIFY) <br /> txy PLEASE BE ACCURATE'r COMPLETE <br /> �VATER 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 /> ' ' 1ESTIMATES) YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING • 5 (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft} <br /> TOTAL DEPTH OF COMPLETED WELL Jq-5—{Feet) "May not be representative of a well's lmg--term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE(2:�) FROM SURFACE TYPE <br /> DIAx w o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) ¢ w2•- a GRADE DfAMETER OR WALL TF ANY MENT TONITE FILL FILTER PACK <br /> Fl to Ft L> Qa (Inches) THICKNESS (inches) Ft to Ft (TYPEISIZE) <br /> 0 �� �L1 1 PVLS ell,4 � 3 1 <br /> q0 M—s-tu krO L4 0,01 <br /> VV I <br /> I <br /> I <br /> ATTACHMENTS (:�L) CERTIFICATION STATEMENT <br /> logic Log <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> 16 Y'Well Construction Diagram NAME <br /> Geophysical Log(s) <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PkINTED) <br /> � t � <br /> JSGIVWater Chemical Analyses �y� r C� <br /> Other S, 1 f, ADDRESSf <br /> t CITY STATE ZIP <br /> Lac) <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed C 57 LICENSED WATER WELZ TOR P DATE SIGNED C 57 LICENSE N MBER <br /> DWR 188 REV 05 D3 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />