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ORIGINAL STATE OF <br /> File with DWR WELL COMPLETION CALIFORNIA <br /> D ONLY - b N F N <br /> page I Of Refer ro fr+afrucum, Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No AT No °e{]34509� `�; ;k„� ❑ ❑ <br /> ate Work Beg<u} kaglp_!E�15, Ended l( � o - LATITUDE LONciTUDE <br /> UX0 Penn(!'Agent nTca <br /> Permit No 0d 9 Permit Date 0 b APN/TRSIOTHER <br /> GEOLOGIC LOG <br /> ORIENTATION (4) X36 FtttCAL HORIZONTAL —ANGLEName- <br /> DRILLING <br /> WELL OWNER <br /> DRILLING ---;�ECIFY) N.une L+~LL 1J1� <br /> DEPTH EFROM�� METHOD FLUID ng Address <br /> SURFDESCRIPTION r 570 <br /> Ft to DGscrihematerial grain size Cnff)r eft CITY Q STATE ZIP <br /> + ILk JL:6 efamWE LOCATI V <br /> I I t <br /> Address 5 • lv , <br /> City <br /> County <br /> APN Book ('age Purrel.��fj 19e0aZQ <br /> a `} Township r-911:55 <br /> _Run a.�5�Section A09+ r ` Latitude 37 46 NORTH Longitude IV L auo + 08 WEST <br /> + I DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (.x:) <br /> NORTH t -y MO NEW WELL <br /> I I <br /> LIDDIFiCAT10NlREPAIR <br /> Other(SPeclly) <br /> 1 I ' <br /> Pmcadw”and MaForfrls <br /> r Under VEQLOGfC LOQ y <br /> PLANNED USES (.4) <br /> WATER SUPPLY <br /> + — Da+neatic _ Public <br /> I i <br /> — 101211an — Ind"Ir+al <br /> I 1 <br /> MONITORING <br /> I TEST WELL <br /> CATHODIC PROTECTION <br /> I I HEAT EXCHANGE <br /> + ! DIRECT PUSH <br /> ` f , INJECTION <br /> 1 1 <br /> VAPOR EXTRACTION_ <br /> I I SPARGING <br /> SOUTH ,.- <br /> f!llrarrafr or AlrwrriGr Urdaxn df SlrrerU <br /> il ne Rrxrrlx B+rllrfhl;yr REMEDIATION <br /> I + Flutex Rkerr ete mul effnfll a nm1t se nrlillflru+nl +vq�rr If OTHER(SPECIFY) <br /> ufYr anj PLEASE HE ACCIURArE&COMPLET'� <br /> 1 1 <br /> + I WATER LEVEL & YIELD OF COMPLETED WELL <br /> r + DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> + I DEPTH OF STATIC <br /> + <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> 'EDTA(, DEPTH OF BORING (Feet) <br /> ESTIMATED YIELD• (GAM)&TEST TYF <br /> TEST LENGTH (Kra) TOTAL DRAWDOWN (FI) <br /> TOTAL QEPT)I OF CO�IPLEThn WELL {Meet) 'May not be rep TSerrW=r of a-,ell's lou -teen yreld <br /> DEPTH CASING (S) <br /> BORE- DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() <br /> DIA' S MATERIAL INTERNAL GAUGE SLOT SIZE <br /> 17 to FL FROM SURFACE CE Ponia <br /> EN E FILL TYPE <br /> ;Ir+chae} <br /> (TYPEISIZE) <br /> � GRADE DIAMETER OR WALL IF ANY FILTEA PACK <br /> yy <br /> L6 � <br /> Michas) THICIOHESS (fcel+oa) R. to FZ MENT) �) (�) <br /> t <br /> + I j <br /> I 1 � <br /> I <br /> I + <br /> ATTACHMENTS {_) CERTIFICATION STATEMENT <br /> — Geowc Log I the undersigned,certify that this report I$complete and accurate to the best of my knowledge and belief r <br /> — WeD COnstruCtiOn Diagram NAME QU � C <br /> GmPhyslcal Lags) (PERSON RRNL OR CDRPDRATIGN) (TYPED DR PRINTED} <br /> SciVWatar Chy[e-m) AnalysesR. <br /> Other `1- ADDRESS , CITY STATE 11P <br /> ATFACH ADOIrIDNAL INFORMATIO P IT EXISTS + 4 <br /> 6 <br /> EEL DRILLERlAIRH iE0 RfPREWNI'AmVE OA SIGNED C,57 110ENSE M INSER <br /> LA%R Thi RM 1147 IF ADDITIONAL SPACE IS NEEDED, USE NEXTCONSECUTIVELY NUMBERED FORM <br /> f <br /> F � <br />