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ORIGINAL STATE OF CALIFORNIA DyjR W§g ONLX - 00 NOTm Fl <br /> File With DWR WELL COMPLETION REPORT <br /> Page—of Refcr to Instruction Paulphlet STATE WELL NO/STATION NO <br /> Owner's WeQ NO ,0345f 5, <br /> s ElE] <br /> to Work Began , Ended Alf LATITUDE LONGITUDE <br /> Permit Agency tf n <br /> Pernvt No Permit Dk-j5 APNITRSIOTHER <br /> / GEOLOGIC LOG WELL OW ER <br /> ORIENTATION (±) V VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Nam a Is - <br /> MRETHODTH FRM FLUID ILLING Mailing Address •O <br /> RESU1-1 Al- <br /> RFACE DESCRIPTIONfflmi" <br /> Ft to FL Describe Anterial grain size,color etc CITY LOCATSTATE XIP <br /> O a I Address w L r <br /> -5 city <br /> County <br /> APN Book Page Parccl a1 141 &� <br /> ' 3 r TownshlpTa 5 R Section 140 <br /> ' ' T;OF Latitude.�� 1 46 1 4TH Longitude 1 1 1 WEST <br /> I ` DEG MiN SEC DEG ON SEC <br /> LOCATION SKETCH ACTIVITY (:) <br /> 1 1 NORTH — NEW WELL <br /> MODIFICATI eEPMR <br /> _„-., <br /> ! 1 Deepeepen <br /> Other(Specify) <br /> 1 <br /> le. <br /> 1 <br /> DESTROY(Desalbe <br /> i I Proesdurea elld MetareN <br /> Under"GEOLOGIC LOG) <br /> t I PLANNED USES (4) <br /> WATER SUPPLY <br /> Domestic Public <br /> t 1 lotystion ,._,. Industrial <br /> Cnr <br /> 1 1 } MONITORING- <br /> 1 1 TEST WELL�. <br /> 1 1 CATHODIC PROTECTION�- <br /> HEAT EXCHANGE- <br /> I 1 <br /> DIRECT Pusrl._._ <br /> t E <br /> INJECTION- <br /> t VAPOR EXTRACTION— <br /> t t SPARGING«. <br /> 1 1 SOUTH REMEDIATION <br /> lllilstrnte or 0mrLLe Dbtancc ref Well from&Aa( ,Bnllrlings OTHER{SPECIFY)— <br /> t Fences Rturs etc awl atfarli a trial) xe ndrhrlonnl yrgxr!j <br /> necrsurry PLEASE BE ACCURATE 0 COMPLETE <br /> I 1 WATER LEVEL h 'YIELD OF COMPLETED WELL <br /> I 1 <br /> DEPTH TO FIRST WATER (FL): BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC <br /> WATER LEVEL (FL)S DATE MEASURED <br /> ' ! ESTFMATE6 YIELD' (GPM)a TEST TYPE <br /> TOTAL DEPTH OF BORING ?Feet) TEST LENGTH (Hm)TOTAL DRAWDOWN—(Ft) <br /> TOTAL DEPTH OF COMPLETED WELL May not be apmentauve of a well's ton -term yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(_ <br /> DIA MATERIAL! INTERNAL GAUGE $LOT SIZE CE(Inches) S GRADE DIAMETER OR WALL IF ANY MENT jT=Ej FILL FILTER PACK <br /> FL to FIL (IWJwe) THICKNESS (nwftes) Ft to Ft (TYPEISIZE) <br /> (�) (=) (�) <br /> t <br /> I 1 <br /> I <br /> t 1 <br /> ! I <br /> 1 I <br /> ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> _ Geologic Log 1,the undersigned,certity that this Report Is complete and accurate to the best of my knowledge and belief <br /> _ Well Constnlctlon Diagram NAME C :ZAK <br /> �5d(PERWK F! "Ri OR u cTIDW ED OR�PRIN[ED) �t 1 F I�S <br /> — Gowhystcal Lags) 4 N V <br /> ._ 5okU4Veter hem lyses <br /> XZ'Other 64 ADDRESS s CITY STATE ZIP <br /> ry p <br /> ATTACH ADDITIONAL lNFOAMATIO !F fT EX15T'S S4rmd ` <br /> WELL DRILLERIALITILDMI REPRESENTATIVE D SI D C 57 LICENSE NUMBER <br /> D" 188 REV II Vs IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />