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ORIGINAL STATE OF CALIFORNIA 12WA USEY — D NFILL Itt <br /> File with DWR WELL COMPLETION REPORT <br /> Page—of Refer to Inttruat)on Pamphlet (STATE WELL NO/STATION NO <br /> w>4ij, <br /> Owner's Well No — No 803�1� ,e`t#- ('„ 1Lj <br /> ❑ <br /> Wcml <br /> Work Began /a`t '? Ended a 5 4� LATIruDE LONGITUDE <br /> Pennit Agency t,L+ vlr <br /> Permit No <br /> ,D APNrTRSIOTHER <br /> E7i�r-[_ a�J�O _ �Permit Date <br /> /- GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) V VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Na1ne <br /> DRILLING <br /> METHOD 1.110 Mailing Address <br /> DEPTH SURFACE DESCRIPTION7t7 <br /> FL tD FL Acscribe material,grain size color, etc CI WELL LOCATISTATE ZIP <br /> � I � <br /> Address a O <br /> a r City <br /> County <br /> APN Book Page Parcel a w f 4�/Died! <br /> Township Ran aST <br /> E Section <br /> ' Latatude 3 7 �{S, ql Longitude .Lai 1–�,d_8 WEST <br /> 1 I DEG MIN SEC DEG MIN SEC WI <br /> EST <br /> SKETCH ACTIVITY (4) <br /> NORTH ^ NEW WELL <br /> MODIFICATIONIREPAIR <br /> I , — Dampen <br /> r i _ Other(Spectty) <br /> PtoceUnder 'ram and MalLOG <br /> Under 'GEOLOGIC LOG J <br /> PLANNED USES (y) <br /> t I WATER SUPPLY <br /> Domestic Public <br /> I I <br /> Irnpatlen ..,_ Industrial <br /> MONITORING <br /> 1 TEST WELL <br /> t 1 CATHODIC PROTECTION <br /> I HEAT EXCHANGE <br /> DIRECT PUSH <br /> 1 1 <br /> tWECTION_ <br /> VAPOR EXTRACTION <br /> 1 1 <br /> SOUT <br /> H <br /> SPARGING <br /> 1 I <br /> Ilhul(rrdr sir Uenxribc Dfaiaucr of!Viii frinN Rrrlrix $n!&JInXx REMEDIATION <br /> I I Fews Riven etc and attach a ala [lar additional?Ngxr If OTHER(SPECIFY) <br /> necesmn) PLEASE BE ACCURNE,&COMPLETE <br /> 1 � <br /> 1 i <br /> WATER LEVEL do YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (FL)BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)R DATE MEASURED <br /> 1 1 <br /> ESTPMATED YIELD' (GPM)a TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN,,,_.`(FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) mat be represmtaHve of a welds long-term yield <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(- FROM SURFACE TYPE <br /> DIA MATERIAL/ INTERNAL GAUGE SLOT SIZE CE eEN <br /> �cneal GRADE FILTER PACK <br /> a DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> FL to FL ( (Inch") THICKNESS (Inches) FI to FL (TYPEMIZE) <br /> � bbblll � <br /> I <br /> t I <br /> I <br /> I , <br /> 1 � <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Lag 1,the undersigned,cer6liy that this report Is complete and accurate to the best of my knowledge and belief <br /> — Wall CottstructIort Diagram NA EA_ft&-*Wm 21c.G r�+i� C 4 �/J_ C <br /> PERSON, FIRM, OR CORPORATION) (TYPED OR PRWTED} <br /> Geophyaksrl Logs) b ^r uE� � O ! /� n <br /> S01YWater Cheml lyses TK 0-4 <br /> OttLer AGGRESS CTLY STATE A 71P <br /> ATTACH ADDITIOMVAL INFORA14 TIt7N F IT EXISTS 8$ r Q <br /> WELL ORIIiER! Rl2E0 REPRESENTATIVE ATE SI NED C 57 LICENSE NUMBER <br /> DwA INS REV 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT'CONSECUTIVELY NUMBERED FORM <br />