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own USE ONLY -- D NO FILL IN <br /> ORIGINAL STATS OF CALIFORNIA <br /> File with DWR WELL COMPLETION REPORT STATE WELL NO/STATION NO <br /> Page--L of Refer to Tnetnrctlon Pamlphlet ❑ <br />' Owner's Well No Mw-Z _ No eQ12893 LATITUDE ❑ LONGITUDE <br /> WWork Began -Z -O v Ended - 2 .p <br /> al Permit Agency OAJOHA9 ecudzrl E"NV1bl A'AssiYIAL- y�11>rii�4P7i APNTTRSIOTHER <br />' Permit No Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (z�) _VERTICAL _HORIZONTAL _ANGLE -(SPECIFY) Name S� <br />' DRILLING FLUID Mailing Address 2 <br /> DEPTH FROM METHOD G <br /> SURFACE DESCRIPTION CITY STATE ZIP <br /> FL to FL Drscrtbe material grant st:e calor etc WELL LOCATION <br /> p x, y�1.ptLl (pw Address 1- <br />' L City <br /> County 16 <br /> County <br /> APN Book--Al Page31[afli—Parcel Z z � -- <br /> Township T.2 S Range E Section 21 <br /> Latitude 3-1 , 44 1 41 NORTH Longitude 12-1 - 7-151 51 WEST <br /> DEG MIN SEC <br /> DEG LOCATION SKETCH ACTIVITY (�) <br /> 1 I <br /> NORTH • NEW WELL <br /> OilMODl F1CATIREPAIR <br /> Deepen <br /> - Other(Specify) <br /> DESTROY! i <br /> 1 1 $� I I X Procedures(Describe <br /> Materials <br /> Under GEOLOGIC LOO I <br /> r r PLANNED USES (=L) <br /> 5QIV1Al1I>SuPIAfxr WATER SUPPLY <br /> Domestic Public <br /> :r I Irrigation Industrial <br /> _6 <br /> I 1 <br /> 3 ssc MONITORING — <br /> 0q�1� � TEST WELL <br /> $111�91tnI(e G] <br /> } CATHODIC PROTECTION _ <br /> i r 3 y HEAT EXCHANGE— <br /> r DIRECT PUSH <br /> r 1 INJECTION— <br /> VAPOR EXTRACTION — <br /> i <br /> ' SPARGING <br /> 1 I <br /> SOUTH REMEDIATION - <br /> r Ilfnstrnte or Deviol Drrtal rf Well finals iReads Braldill OTHER(SPECIFY)— <br /> Fnrtcer Smelt eft and ral a nine ll arldll,u:,rrl prep i if <br /> I i necessanl PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Fi) BELOW SURFACE <br /> DEPTH OF STATIC <br /> 1 I WATER LEVEL (Ft)&DATE MEASURED <br /> r ESTIMATED YIELD (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLk"ILD WELL (Feet) `May not be representative of a well's long-term yield <br /> ' CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE MOLE TYPE O ) <br /> DIA a MATERIAL! INTERNAL GAUGE SLOT SIZE C:N- <br /> TTON <br /> N FILTER PACK <br /> (Inches) a GRADE DIAMETER OR WALL IF ANY MITE FILL TYPElSIZE] <br /> FI to FL (Inches) THICKNESS (Inches) Ft to Ft ) (�) <br /> rn � <br /> r ' <br /> 1 ' <br /> I ' <br /> ATTACHMENTS (if!.) <br /> CERTIFICATION STATEMENT <br /> KI,the undersigned certify that this report is complete and accurate to the hest of my knowledge and belief <br /> Geologic Log <br /> Well Construction Diagram NAME \h1t o`l <br /> ex <br /> (PERSON FIRM OR CORPDRATIOM (TYPEQ OR PRINTED) <br /> sic <br /> Ge <br /> _ ophyal Log(s)Geophysical <br /> Chemical Analyses +2 V se `S � <br /> ADDRESS CITY STATE ZIP <br /> Other !"a -LO—V52-1, <br /> ATTACH ADDr710NAL INFORAMTION TF IT EXISTS Signed Ell eOftED R DATE S113N D C 57 LICENSE NUMBER <br /> ' DWR 188 REV 11 Il: IF ADDITIONAL SPACE IS N EOE USE EXT C NSECUTIVELY NUMBERED FORM <br />