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ORIGINAL STATE OF CALIFORNIA gWa USgY — 129 N T FILLN <br /> File with DWR WELL COMPLETION REPORT <br /> Page—of Refer to Instrlicttnn parujulrlet STATE WELL NO/STATION NO <br /> Owner's Well No �"^ No lull <br /> ke034516'�-�' '�T ❑ ❑ <br /> to Work Began 6 Ended _ � r _ <br /> LATITUDE LONGITUDE <br /> Permit Agency <br /> Permit No C0ALka3`` Permit Date /G APNITRSlOTHER <br /> '�— GEOLOGIC LOG 1 WELL OWNER <br /> ORIENTATION (4) _VERTICAL HORIZONTAL _ANGLE �_(SPECIFY) Naive QI-'t'` <br /> DRILLING <br /> DEPTH FROM METHOD FLUID M��g Address S <br /> SURFACE DESCRIPTION <br /> FL to FL Describe inaterial gran size, talar eta CITY � STATE ZIP <br /> .1 rr a WE LOCATIO <br /> ' Address <br /> 9` ice - city Tr J��Ile _ <br /> County 4 -70 ti I v�- <br /> ' .46 <br /> APN Book Page Parcel a! D I <br /> ' <br /> Lin— Township Tom[ 'Ran a�3,5:�Section <br /> 1 I C SS Latitude 3 �r-� �aNOFm-I Longitude 44 l :A(w6A WEST <br /> i r DEG. MIN SEC DEG MAN SEC <br /> LOCATION SKETCH ACTIVITY (=) <br /> I r NORTH <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other lher( <br /> _ (Specify) <br /> DESTROY(Dolsod e <br /> Procedures and Mat <br /> I ' Under Undor LOG GEOLOGIC LOP 1 <br /> PLANNED USES (4) <br /> I I WATER SUPPLY <br /> Da ostk PutAic <br /> Irrigation Industrial <br /> I 1 <br /> MONITORING.._ <br /> I TEST WELL— <br /> ! 1 <br /> CATHODIC PROTECTION_.._.. <br /> HEAT EXCHANGE <br /> I I DIRECT PUSH <br /> I 1 INJECTION <br /> 1 VAPOR EXTRACTION <br /> I r SPAFTOAVG <br /> I I SOUTH REMEDIATION <br /> lUnsnrde or Dewrlbe Divurner of Well fnrnr R wets BulhlLan <br /> Fences Rhers rte grid rmndr n slapp VW erirlitfund�xrlxr OTHER(SPECIFY) <br /> Ireerssanj PLEASE BE ACCURATE&COMPLETE <br /> 1 WATER LEVEL & YIELD OF COMPLETED WELL <br /> l 1 <br /> I I DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)3 DATE MEASURED <br /> ESTIMATED YIELD (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING Feet) TEST LENGTH (Hra)TOTAL DRAWDOWN- (PI.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a we1Ps ion term yreld <br /> DEPTHBORE CASING (S) DEPTHANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE =1 FROM SURFACE TYPE <br /> DIA. MATERIAL If INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Indies) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> FL to FL OnGwa) THICKNESS (Inches) FL to FL (`) ( (�) (TYPE)SIZE) <br /> r <br /> r 1 <br /> 1 <br /> 1 r <br /> 1 I <br /> ' ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> 1,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br /> �. QeDlapic Log /� u I�^ m n �r <br /> _ Well Construction Diagram NAME fe)oa _o l,©, . ) --- <br /> WEERRSON FIRM, ORkt S`CORPORATION) (TYPED OR PRINTED) / Q <br /> Geophysical Log(s) O U L R O I O V i s ! V57 <br /> SoillWater'Cheml Analyses <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACH ADVITIONAL INFORMA TI 1F IT EXISTS Swrled � � <br /> WELL DRILUR/AUTHMZED REPRESENTATIVE TE SIC EO C.57 LICENSE NUMBER <br /> DWR 18N REV 11-u; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERE=D FORM <br />