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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FELL IN <br /> File with DWR WELL COMPLETION REPORT F I 1 <br /> Paae 1 Of Refer to Instruction PamUhlet STATE WELL NO/STATION NO <br /> 0,%mer's WellNo Mw-lc _ No 0932164 1 1 1I ELF-= <br /> I <br /> Date Work Began -`1 -C�_ Ended I�`�5 �� LATITUDE LONGITUDE <br /> cal Penna A en � r "v f ) r � f— I I I I I <br /> C}' � � � ���� AoN1TR51PTHER <br /> Permit No Cv 5 I . Pe:m1t Date 12-5-05 <br /> GEOLOGIC LOG WELL OSN NER <br /> ORIENTATION (2L) _VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Na171e <br /> MRILLING' F;OD '1,jfY I FLUID v al Address u <br /> DEPTH FROM I-tl. �}'4�L1 STATE f <br /> SURFACE DESCRLP ON r '`. <br /> Des matersaI grain size color etc �rrY r� <br /> FL to ZIP <br /> FI a ' WEL Lt CA 0 f <br /> Address v <br /> - ju y - ,n S <br /> a Lr 5 cll ty-f �J r. Jrs1 <br /> CPN Book Page Parcel <br /> s <br /> Y Township ' Aange Section <br /> at I N Zona IW <br /> DEG MIN SEC o DEG MIN SEC <br /> LOCATION SKETCHAt 'ITY <br /> t l 1 <br /> NORTH {/NEW WELL <br /> MODIFICATION/REPAIR <br /> ,,,�--..� �.,� -', ✓ See �fc�b�i.>� — Deepen <br /> Other(Speedy) <br /> I /•�I�., ' 1 % - �� DESTROY(Describe <br /> Under Procedures 1 <br /> GEOLOGIC LOG} <br /> USES (2L) <br /> WATER SUPPLY <br /> Domestic — Public <br /> I l Irrigation Industrial <br /> I I w ¢ MONITORING _ <br /> LL] <br /> TEST WELL— <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> i I INJECTION _ <br /> I I VAPOR EXTRACTION <br /> SPARGING <br /> tSOUTH REMEDIATION <br /> Illustrate or Describe Distance of bVe,7 from Roads Buachngs <br /> i Fences Raters etc and attach a msp Tjse additional ppaper If OTHER(SPECIFY) — <br /> necessary PLEASE BE ACCURATE fr COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 1 <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ' ' J � � ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEP'T'H OF BORING 1,—(Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 1 5 (Feet) "May riot be representatrve of a Well's long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE(—) FROM SURFACE TYPE <br /> HOLE <br /> rr w INTERNAL GAUGE SLOT SIZE CE BEN <br /> DIA Y w O d MATERIAL/ FILTER PACK <br /> Inches z z a DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to Ft ( ) m oc� J GRADE (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> I <br /> 1 I � 1 �'�.s 0 <br /> a� <br /> 1 V I 10 <br /> i <br /> I ' <br /> ATTACHMENTS (.:L) CERTIFICATION STATEMENT <br /> V/ I the underslg ed certify that this report Is complete and accurate to the best of my knowledge and bellet <br /> �eologlc Log <br /> Well Construction Diagram NAME )f <br /> IP RS N FIRM OR RPORAT DN) (TYPED OR PRINTED) r <br /> _ eophystcal Logs) �i—• � J <br /> odMlater Chem a�ilIIP <br /> IAAnalyses r <br /> Other 4 i� f� � ADDRESS CITY STATE <br /> z6i, <br /> ATTACH ADDITIONAL INFO_RAnATION IF IT EXISTS Signedfol } 9-4)6 <br /> C 57 LICENSED WA ER LL C NT AC R DATE SIGNED C 51 LICENSIMBE—R <br /> DWR 188 REV 05 03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 7BB36 <br />