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y <br /> ORIGINAL STATE OF CALIFOI{1rIA 40T FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page,.......-of- Itefer to Irn.tnrctlnrr Pa+Nplllrt STATE WELL NOJSTATION NO <br /> Owner's Wei No �� ' No ��)3�`4.51'Q 1,r 6 1'" r"°; ❑ ❑ <br /> 0ate Work Began m a`� d� l LATITUDE LONGITUDE <br /> LOQd Penn(t jaiY+ <br /> Pernut No 00 Permit Date i GS APNITRSIOTHER <br /> / GEOLOGIC LOG WELL R <br /> OWNE <br /> ORIENTATION (�} V VERTICAL —HORIZONTAL —ANGLE —(SPECIM Mune <br /> DRILLING <br /> DEPTH FROM METHOD FLUID M ng Address <br /> SURFACE DESCRIPTION <br /> Ft to Ft Describe material groin Size calor etc rfY STATE ZIP <br /> 30 i WELL LOCAT N <br /> I G5 Address <br /> City <br /> County <br /> APN Book Page pae] 101q180ao <br /> TownshL 3"7�S Range S& section <br /> "Wxr �=" <br /> Iatxtude 55 d-t NaRTH Longitude ! o-la O WEST <br /> -�� DEG MiN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH W4a d Lodr NEW WELL <br /> I ` ` � <br /> 1 i <br /> MODIFICATiONlREPAIR <br /> ..-^- Deepen <br /> r Other(Specify) <br /> err`—', _li DESTROY(D"colbo <br /> I ' Procedures end Materlals <br /> Under GEOLOGIC LOQ) <br /> PLANNED USES (_) <br /> WATER SUPPLY <br /> I D001e5I10 <br /> �- Public <br /> F- Irngation (ndualrial <br /> I 1 <br /> w MONITORING <br /> I I TEST WELL <br /> CATHODIC PROTECTION�. <br /> HEAT EXCHANGE <br /> i t DIRECT PUSH-� <br /> a I IWECTION <br /> 1 <br /> VAPOR EXTRACTION <br /> SOUTH SPAP,GING <br /> 1 <br /> 11lustnrtr r�r 1Jlrarrirx 1)lxlrtrrn if <br /> f{irrll jrnrn Rraxlx Arrllrllu;,n REMEDIATION <br /> i I Aan& Akers etc and R11.7di a„yrfr C'xr nrlrllfFurml�kr�rr if OTHER(SPECIFY) <br /> I mrrxwnj PLEASE HE ACCURATE b COddPLET <br /> I , WATER LEVEL Sr YIELD OF COMPLETED WELL <br /> I DEPTH TO FIRST WATER <br /> (Ft) BELOW SURFACE <br /> I DEPT OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD• (GPM)a TEST TYPE, <br /> TOTAL DEPTH OF BORI14C (Fret) TEST LENGTH (HM)TOTAL DRAWDOWN_(Ft) <br /> TOTAL DEPTH OF COMPLETED WELL ------ beet) "May not be entatmr of a u�ell's loo rem teld <br /> DEPTH CASING (S) <br /> FROM SURFACE BORE- DEPTH ANNULAR MATERIAL <br /> HOLE TYPE { FROM SURFACE <br /> DIA TYPE <br /> )S" MATERIAL t INLXR] <br /> GAUGE SLOT SIZE <br /> ("'a1e0) ° GRADE DIOR WALL IF ANY CNT TONTTE FILL <br /> FT to FL FILTER PACK <br /> THICKi(l SS (Inches) PL to FL (TYPE/StZE) <br /> i <br /> I 1 <br /> I <br /> I I <br /> r I <br /> ATTACHMENTS (=) <br /> CERTIFICATION STATEMENT <br /> Geologfe Lop I,the undersigned,certdy that this report Is complete and accurate to the best of my knowledge and belief <br /> Wall ConslrUCtIon Diagram NAME N <br /> . GeophysIeW Log(s) (PERSON MIR OR CORPORATION) (TYPED UR rmulltA) <br /> JSoluwater Chemo nayses o 1LLLkC k.- RD rQ1 10— [..� 7 <br /> Other ` T CfTY STATE �(ZP <br /> ATrACH ADD1770MC " OAAlI tF Ir' Ism �d a'* 1 /'L3 W <br /> WELL IIRft1EfUAUFHO REPRESENTATIVE 0A SIGNE C 57 LICENSE NUMBER <br /> uuR TNN Rei Ittr, IF ADDIT70NAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM I <br /> 3 <br />