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ORIGINAL STATE OF CALIFORNIA QW8 USIEFONLY — 02 NOT. IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page_of Refer to Instnrcrlun Pamphlet STATE WELL NO!STATION NO <br /> Owner's WeI1 No, T `3 NO' F' U345�1 ,1 ' bb�{-;_ ❑ ❑ <br /> LATITUDE LONGITUDE <br /> �e Work Sagan aD05 , End d <br /> �oc,a Permit Agency r� <br /> Perrrut No — 41y a? Permit Date a4x) APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�t) & VERTICAL -HORIZONTAL -ANGLE -(SPECIFY) Naive <br /> DRILLINFLUID Malhng Address a K <br /> DEPTH CW(5a— METHODE DESCRIPTION 5 d <br /> FL to FL DEscrtbe material,grain size,calor, etc CITY 41 STATE Lill <br /> I IW L LOCATI <br /> Address 449u VA, <br /> 0—C Yk— <br /> ' ' County <br /> ' S APN Book Page Parcel <br /> ' a v Township Range Section <br /> Latitude 3-1 M5D <br /> 1.q�WOF1TH Longitude N SEC at a� 05 wEST <br /> DEG LOCATION SKETCH ACTIVITY 0J) <br /> NORTH NEW WELL <br /> ' r !'r%h& MODIFICATIOWREPAIR <br /> t 1 � p C _ Deepen <br /> Other(Specify) <br /> I r <br /> t I ? DESTROY(Owen!» <br /> Procedures area is <br /> Under"GEOLOGICIC LOG J <br /> I I PLANNED USES (i::) <br /> I I WATER SUPPLY <br /> Domes cc Public <br /> I 1 <br /> �.., <br /> irrigation ._... Intlustrle! <br /> I I WWd^ MONITORING <br /> I I TEST WELL <br /> 1 I CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> I I <br /> DIRECT PUSH <br /> I t INJECTION <br /> I t VAPOR EXTRACTION <br /> I 1 SPARGING <br /> I ISOUTH REMEDIATION <br /> 111tuimte or Lkacrlhe Dldauce of W-11 from&mdr Brrfblluas <br /> 1 I Fences Rlura etc arid alloLit a ina7r v add[Hunid w,r OTHER(SPECIFY) <br /> necessanj PLEASE BE ACCURATE&COMPLETE. <br /> 1 t WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 1 <br /> I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> r t DEPTH OF STATIC <br /> WATER LEVEL (FI)&DATE MEASURED <br /> ESTIMATED YIELD^ (GPM)d TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (HrL)TOTAL DRAWDOWN - --(FI) <br /> TOTAL DEPTH OF COMPLETED WELL rFeet) 'May not be repriventative of a well's lura -tarn rrld <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> HOLE <br /> SURFACE <br /> BORE- <br /> FROM TYPE zL FROM SURFACE TYPE <br /> DIA. MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN FILTER PACK <br /> (Irlchea) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to FL (ipoh e) THICKNESS (hiches) FI to Ft (�) {�) {�) (TYPESIZE) <br /> I <br /> r I <br /> 1 <br /> r I <br /> r I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic!_vg I,the undersigned,earthy that this report is complete and accurate to the best of my knowledge and belief <br /> _ Well Construction Diagram NAMeG UC <br /> (PERSON R OR CORPORA ) (TYPED OR PRINIEO) <br /> _ <br /> GeoplviftalLog(s) <br /> Soll/water G A <br /> d k o g p— 'LD <br /> s� eADDRESS CITY <br /> YS'T STATE ! I s <br /> IIP <br /> Other S�juo_- <br /> %�3411 <br /> ATTACH ADAITIONAL INFORMATION IF IT EXISTS � ! t� <br /> WELL DRILLERlAUTHO D REPRESENTATIVE SIGN C-51 LICENSE HUMBER <br /> DWR IWl REV 1147 IF ADDITIONAL. SPACE 13 NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />