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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page I ofA— Refer to IrnsNiiction Pamphlet STATE WELL NOtSTATION NO <br /> Owner's Well No K w r I No 811086 [3Date \'Volk Began } x 3 9 Ended 1[2-3,19 9 LATITUDE LONGITUDE <br /> Local PermitAgencv �R11 Taq!bKlti Coshty POS 1t E-ND ApNITRSIOTI <br /> PeHEn <br /> rmit No b�_9 �1_ -Pei mit Date r�3 ! 99 <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�} —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name S I <br /> N A DRILLING C RDx 9} <br /> DEPTH FROM METHOD FLUID Mathna Address <br /> SURFACE DESCRIPTION M c1�K G A .9SS4 _ <br /> FI to Ft Dcscrrbc Ircatcnrrl �,rrrrrr size tutor etc <br /> CITY STATE ZIP <br /> � WE L LOCATION <br /> Address <br /> 1'1k ed_ q%A gbgi% dC11eCounty $aH TOq!jW l� <br /> e-1 Wit 10 .j r�xehlebtt. APN Book Page Parcel <br /> ' Ildoitvllete -SNIrrs v jqCt6L Township Range Section <br /> t�l 1 N e S r'' a Latitude I I NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH _ NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> 1^ E MRP — Other(Specuy) <br /> a — <br /> T <br /> "t A I� G►( E� DESTROY(Desc <br /> �f Procedures and Matalereals <br /> Under GEOLOGIC LOG J <br /> PLANNED USES (�) <br /> I I WATER SUPPLY <br /> Domestic Public <br /> � <br /> irrigation Intlu st tial <br /> /1 ~ <br /> W ¢ MONITORING <br /> W <br /> i TEST WELL_ <br /> i I CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> i INJECTION _ <br /> VAPOR EXTRACTION <br /> PA IN <br /> SOUTH <br /> REMEDIATION <br /> Ilhnirntc ui Ucsufhc Drstducc irf 1f ell iirnr Roads Berl(hnhs <br /> I I Funis Rat r� itc eind attach a nuip UNc adelitunislt f elptI OTHER(SPECIFY) <br /> wccwiiy PLEASE BE ACCURATE&COMPLETE <br /> i WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i I DEPTH OF STATIC N A <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> I 1 <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) N A TEST LENGTH <br /> (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be tepresentattve of a well's long-terra yield <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE TYPE <br /> DIA z °c a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) w z� a GRADE DIAMETER OR WALL IF ANY MENT ITONITE FILL FILTER PACK <br /> cc Ft to Ft m c�io LL (Inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> (.::L) <br /> I <br /> I I <br /> I I <br /> I <br /> I I <br /> I I <br /> ATTACHMENTS (t) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned, certify that 1t1111 111r,his report Is complete and accurate to the best Of my knowledge and belief <br /> ..,_, Well Construction Diagram NAME `! + W D r'11` <br /> (PERSON FIRM OR CORPORATION) (TYPED R PRINTED) <br /> Geophysical Log(s) <br /> 7 Chemical a n. n <br /> 8 S 't) v to <br /> Soil/Water lyses G R 9 45 <br /> Other stP '' �a <br /> ADDRESS � CITY � � STATE�O �Ih <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS 'Sign r V � <br /> ANTHOR0D REFRESENTAVVE O E SIG D C 57 LICENSE NUMBER <br /> D4%R ISR REX It 97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />