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4 <br /> 1�, ORIGINAL. STATE OF CALIFORNIA USE—ONLY — Q0 8QT FILL IN <br /> File with SWR WELL COMPLETION REPORT <br /> Page—of Refer to Instnrctfun Prtnlphlet STATE WELL NOISTATION NO <br /> O�vneR's Well No Ate- No. �bO34,518 ,lw l ❑ ❑ <br /> to Work Began �a 7 , Ended LATITUDE LONGITUDE <br /> al Permit Agenc SQK APNrrRSlOTHER <br /> Perrrut No a Perrot Date 1'0 <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (,j�) VERTICAL HORIZONTAL _ANGLE —(SPECIFY) Natne <br /> UREM ET DRILLING FLUID M g Address K 54 <br /> SURFACE <br /> DESCRIPTION 570 <br /> FL to Ft Describe inater(al grain size, color, etc CITY STATE zip <br /> r <br /> WELL LOCA <br /> Address T <br /> a5 ✓ <br /> — <br /> ' ' Countys r� i <br /> A P N Boole Page arc cl aI /goA <br /> ' Townships Ranygp�e RsE <br /> := SCctton <br /> I NORTH OR Latitude-X7146 TgWEST <br /> DEG MINI SEC DEG MlN SEC <br /> LOCATION SKETCH ACTIVITY (4) <br /> i I NORTH <br /> NEW WELL <br /> I I may/ MODIFICATION/REPAIR <br /> — Deepen <br /> .« Other(Spad1Y) <br /> I t cTROY(DlecrPoe <br /> , I � Procedurrr and Aletertale <br /> Under GEOLOGIC LOG J <br /> r Vu` PLANNED USES (4) <br /> I I WATER SUPPLY <br /> �. Domestic Public <br /> I I <br /> F lr pawn Iriclumtrml <br /> I I MONITORING�. <br /> 3 TEST WELL <br /> I ! CATHODIC PROTECTION- <br /> NEAT EXCHANGE <br /> I I <br /> DIRECT PUSH�. <br /> i I INJECTION...,`- <br /> I I VAPOR EXTRACTION <br /> 1 i SPARGING- <br /> i I SOUTH REMEDIATION <br /> Illustrate or Dewr(Ix Distance of tVell fnim Roark Bullrlln A OTHER(SPECIFY] <br /> i I Fences Ithers etc and attnA a nla t w adds tuna!�xrNi r if <br /> neceatenj PLEASE BE ACCURATE b COMYI.ETE <br /> WATER LEVEL dT YIELD OF COMPLETED WELL <br /> 1 I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I I <br /> i DEPTH OF STATIC <br /> WATER LEVEL (Ft)A DATE MEASURED <br /> ' ESTIMATED YIELD' (QPM)A TEST TYPE; „ <br /> TOTAL DEPTH OF BORING _(Feet) TEST LENGTH (Hm)TOTAL ORAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "M not be representattae of a wells!rot -term yield <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> BORE <br /> FROM SURFACE HOLE TYPE[20 FROM SURFACE TYPE <br /> DtA Y MATERIAL! INTERNAL GAUGE SLOT SIZE FMENT <br /> BEN <br /> (k,ches! GRADE DIAMETER OR WALL IF ANY TONITE FILL FILTER PACK <br /> Ft to FL (Ind+aa) THICKNESS (Inerts) FL to FL (�) (=) CrYPFJSIZE) <br /> 1 <br /> 1 <br /> e I <br /> 1 <br /> � 1 � <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned,Certify that this report is complete and accurate to the best of my knowledge and belief <br /> _ Geologic Lop rn A-� �� <br /> Well Constrtiction Diagram NAMF (TYK I/ <br /> (PERSON FIRth OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) U FR IO � !s <br /> /SoMater Chemlca ally CITY f STATE IIP <br /> y Other t; ApCRESS <br /> ATTACH ADDITIONAL INFORAMTIOM lF tr 5XIST3 - ' <br /> WE D IlEER/A(!TH ED REPRESEMATIYE DA SICNE C UCENSE NUMBER <br /> DWR 184 REV 1147 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />