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' ORIGINAL STATE OF CALIFORNIA DWR OSE NLY — DO N T FILL IN <br /> File With DWR WELL COMPLETION REPORT STATE WELL NO!STATION NO <br /> Page of t Refer to lititrreetton Pantphlrt ElElowner's well No AW-5 _ NO e012895 <br /> LATITUDE LONGITUDE <br /> CeWork Began. N-Z�o-fl�_, Ended LG-04 <br /> al Pennit Agency tH�e,... Y APNFrRS10THER <br /> Penmt No Permit Date q-'LI"0S - <br /> GEOLOGIC LOG WELL OWNER <br /> sS�' <br /> ORIENTATION (L) VERTICAL -HORIZONTAL -ANGLE -(SPECIFY) Naini <br />' <br /> DRILLINGOD Maihng Address 2(0 C ►IWe 12A"^n"'r 33r 3EO�Q�_METHFLUID ^ <br /> DEPTH FROM DESCRIPTION SURFACE DEclTy S7ATE ZIP <br /> FL to Ft Describe material gram Size calor etc WELL LOCATION <br /> o f x, It <br /> r dv t.C. 906J �t(LAr17E Address IO ATT !Z <br /> p Lt. NEWS— C0vkMN r City CA 9 NO <br /> County — 14o w <br /> APN Book�3 rage—of Parcel <br /> Township TZS Range EASE Section z-t <br /> Latitude 1*7 1 Nq I q 1 NORTH{ Longitude !21 t 2 S t 51 WEST <br /> DEG MIN SEC DEG MIN SEC <br /> t + LOCATION SKETCH ACTIVITY OL) <br /> NORTHNEW WELL <br /> r i E. 127'p SC. <br /> ' MOD,FICATION/REPAIR <br /> 1 f Q ^ Deepen <br /> _ Other(Specify) <br /> I I <br /> DESTROY(DesGnlle <br /> h + <br /> Procedures L <br /> and <br /> Under <br /> r 1 UnddGEOLOGIC GEOLAGIC lC LOGOG <br /> J <br /> t PLANNED USES (�L) <br /> SOIA�I.�NP. A`TNG WATER SUPPLY <br /> Domestic - Public <br /> Irrigation - Industrial <br /> r ' SBC MONITORING <br /> v Tesr WELL <br /> ' BuILAilu(� R CATHODIC PROTECTION <br /> r BEAT EXCHANGE- <br /> DIRECT PUSH_ <br /> INJECTION_ <br /> � I <br /> VAPOR EXTRACTION <br /> h h <br /> SPMATON- <br /> I , <br /> SOUTH REMEDIATION <br /> I Ill,rstratc or JkscnLc DlstrniGx'of TVcll rnnl[ROMN Bfidelfn„t OTHER(SPECIFY) <br /> Fences Rmert etc and Atfach a nra, n arlrLtruftnl FFur)u+ if <br /> h I Irecestanf PLEASE BE ACCURATE 0 COAfPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> 1 + <br /> DEPTH TO FIRST WATER TO BELOW SURFACE <br /> DEPTH OF STATIC <br /> I I WATER LEVEL TO&DATE MEASURED <br /> + ESTIMATED YIELD (GPM)6 TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLb-ILL) WELL (Feet) May not be representative of a well's long-tern yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE('') <br /> DIA w i MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> ([ncthes) a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL to <br /> FI to FI v (Inches) THICKNESS (inches) Ft to FI (�) (�) (�) (n' <br /> rn � <br /> t 1 <br /> 1 <br /> h <br /> 1 <br /> , <br /> 1 ' <br /> ' ATTACHMENTS (:) CERTIFICATION STATEMENT <br /> y I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> It Geologic Lag 'r <br /> X <br /> Well Construction Diagram v <br /> NAME Igo tgEjs <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTER) <br /> Geophysical Log(s) t2a C,45-171 . <br /> ADDRESS <br /> Chem"]Analyses p �� <br /> DRESS CITY STATE XIP <br /> AL Other _OZ <br /> ATTACH ADDITIONAL INFORMATION !F 1r EXISTSS,gned DA SIGNED RTDCENSE NUMBER <br /> n GRILL OR11111 RE I <br /> DWR RIR REV tH 47IF ADDITIONAL SPACE IS N&Ub USI<Ef CONSECUTIVELY NUMBERED FORM <br />