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51 <br /> ORIGINAL STATE OF CALIFORNIA Dw!j jjSJ ONLY — DO NOT FILL I <br /> File with DWR WELL COMPLETION REPORT <br /> Page_ofRefer to Instruction Pamphlet STATE WELL NO.ISTATION NO <br /> 4� _ <br /> Owner's Well No —� No �e034614 =� �E���� � I I 1 1 17❑ <br /> Work Began M 0100 Endait 50�a LATITUDE LONGITUDE <br /> Cal Permit Agency -2-0cE 1'` � En✓r APNfrR510THER <br /> Permit No aZ�J Permit Date �� �� <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (y) Ae ERncAL —HORszONTAL —ANGLE (5PEo" Na1nek'j Aqvj jr (511 <br /> RC) <br /> ° R <br /> DRILLING <br /> ID Ma11��Arid <br /> DEPTH ress x <br /> DESCRIPTION <br /> FL to FL Describe material grain Size, color, etc CITY STATE 23P <br /> r r, <br /> Address WYJrL LOCATIO <br /> I I <br /> Qty <br /> i <br /> Court; r ►'� ori f u.rYL71 <br /> _ <br /> APN Book Page Parcel t'jl Ro chi O <br /> ' Townslup`��// Range.��Section +]of <br /> 1 r Latitude I't FLU NORTH Longitude_-471 I_ 0 0, 108 WEST <br /> DEG MIN SEC DEG WN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> 4—Ad e" — Deepen <br /> r ` Other(Specify) <br /> r i <br /> r i <br /> ^, DESTROY(8sserlDe <br /> Procedures and Mehrirls <br /> r I Under GEOLOGIC LOG J <br /> r ' PLANNED USES (=) <br /> i WATER SUPPLY <br /> Domestic r.,_ Public <br /> Impetion Industrial <br /> H <br /> I r Lir MONITORING <br /> r �r TEST WELL <br /> 1 r CATHODIC PROTECTION <br /> HEAT EXCHANGE! <br /> r ' DIRECT PUSH....._ <br /> INJECTION <br /> r I VAPOR EXTRACTION <br /> I i SPARGING <br /> SOUTH REMEDIATION_ <br /> Ilam to ar Dewribe DAta)jcr of Well fnrnl Rrxrds Bultd1u <br /> r Fences Mums rtc and attach a Fnap Use additlonel )xr if OTHER(SPECIFY)_ <br /> nacewry PLEASE BE ACCURATE&COMPLETE <br /> r I WATER LEVEL do YIELD OF COMPLETED WELL <br /> r r <br /> r r DEPTH TO FIRST WATER (Fr) BELOW SURFACE <br /> r I DEPTH OF STATIC <br /> WATER LEVEL (FI)d DATE MEASURED <br /> r ESTIMATED YIELD (GPM)E TEST TYPP <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN___ (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL ..,...,__(Feet) *May not be=raentatme of a well's long -term yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE —') FROM SURFACE TYPE <br /> DIA MATERIAL I INTERNAL GAUGE SLOT SIZE CE- I BEN FILTER PACK <br /> (inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> FL to FL (inches) THICKNESS (Inches) FL to FL { } (✓) (✓} (TYPE/SIZE) <br /> I r <br /> r I <br /> i <br /> r r <br /> r r <br /> r ATTACHMENTS CERTIFICATION STATEMENT <br /> — Geologic Lop <br /> I,the undersigned,certify that this report Is complete and accurate to the Hest of my knowledge and belief <br /> Well Construction Diagram 1411 R w~4L r!}7CU ,a�J L L/N G_. Cts, � A j C• -- <br /> (P_ fi, 1`1141101 DR CORPORATIDNI (TYPED OR PRINTED) �7 <br /> ./SoillWater Chemical lyrles _ <br /> y Other r-J'r 44 ADDRESS r - e CITY STATE 21P <br /> ATTACH ADDITICWAL WFORMATIOeHF IT EXISTS 7 g <br /> WELL DRILLERlAUTH ZED REPRESENTATIVE DA SIGN C-5I LICENSER1tMBER <br /> UWR 148 REV 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />