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4 ORIGINAL STATE OF CALIFOBNIA OWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page <br /> STATE WELL NO/STATION NO <br /> Of� R(fer to Irrstrncirou Pnnil+hl[t ❑ <br /> Owner's Well No Mw-3 No 823396 <br /> LATITUDE LONGITUDE <br /> Date 1'lTotk Began Z 9 , Ended } Z; 99 <br /> Local Peiinit Agency 1r <br /> g � � C�Ahi $ i 9 ApNITRSlOTHER <br /> Permit No 019 S 3 6 Permit Date 9•7 <br /> GEOLOGIC LOG IWELL OWNER <br /> ORIENTATION (,!) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name Ms. `'�ly A <br /> DRILLING Mailing Address i -9t <br /> DEPTH FROM METHOD FLUID C A {51 <br /> SURFACE DESCRIPTION �} r7 <br /> Ft to Ft Describe nlatel tal grain srwe color etc CITY STATE ZIP <br /> ELL CATIO 2f <br /> Address <br /> City, C C A <br /> t (4*14 q6z%aaltelL County <br /> ceuitilt, APN Book Page Parcel <br /> I h4t4johita Sj%q" 014icP4. Township Range Section <br /> ' ' + ticty4ii aix& SS I-iQ Latitude NORTH Longitude WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITI (—I) <br /> I I NORTH _ NEW WELL <br /> I MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> I 7 _ <br /> r t S il/� DESTROY(Describe <br /> 77 �- Procedures and Materials <br /> r I Under GEOLOGIC LOG) <br /> A -r r h G E{ F D PLANNED USES (.::L) <br /> I I WATER SUPPLY <br /> Domestic Public <br /> I <br /> t— Irrigation Industrial <br /> coH <br /> I ILU < MONITORING _ <br /> I I TEST WELL <br /> I I CATHODIC PROTECTION <br /> HEAT EXCHANGE �^ <br /> I I OSRECT PUSH _ <br /> INJECTION <br /> I I VAPOR EXTRACTION <br /> I I SPARGING— <br /> SOUTH REMEDIATION <br /> 111ifei atc oI Dcscl Ib( Ontrnicc of Wdl frour Road% Buildn+gs <br /> i Ftwes Rri.cl s etc narl attach a Inappt V%( nddihonnl jirr)+u if OTHER(SPECIFY) <br /> occcssunj PLEASE BE ACCURATE dT COAfPLETE <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> I I DEPTH TO FIRST WATER (Ft) BELOW SURFACE y' <br /> I DEPTH OF STATIC r <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD {GPM} & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) \� /i TEST LENGTH (Hrs) TOTAL DRAWDOWN {Ft} <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) �1j n 'May not he 7epaesentative of a well's long-term yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE r <br /> FROM SURFACE HOLE TYPE(.!:L) FROM SURFACE TYPE <br /> DIA r w O a MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN FILTER PACK <br /> (kriches} a w f r a GRADE DIAMETER OR WALL. IF ANY MENT TONITE FILL <br /> Ft to Ft m L �M (Inches) THICKNESS (Inches) Ft to Ft (� ) ( � ) (� ) (TYPEISIZE) <br /> rn 0 LL <br /> I <br /> I � <br /> I r <br /> I t <br /> I r <br /> I + <br /> ATTACHMENTS (z�) CERTIFICATION STATEMENT <br /> I the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geologic Log V W y,. �u IVIG, <br /> �L^ r <br /> Well Construction Dtagram NAME • + ' ` 0` i ll;``st `h V' <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) CIA <br /> 91511"� <br /> _ Geophysical Log(s) 110. Bey l d�i 5 hr Y I't J { I <br /> Soil/Water Chemic$IMAnalyses CITY STATE ZIP <br /> Other Si � I�l�p ADDRESS ]�/�J <br /> ATTACH ADDITIONAL INFORMATION 1F 17 EXISTS 5rgne 7`'� <br /> WE D ILLER! T 0 1 D EPIESENTAT&F C 57 LICENSE NUMBER <br /> D11 R t&Y BEN 11D7 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSE=CUTIVELY NUMBERED FORM <br />