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QUADRUPOCATE j <br /> STATE OF CAL.IFORIlA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements (.Iiittr•VELL COMPLETION REPOQ <br /> Page Refer fu l,Istrirctrun Pant(�hlet :i STATE WELL NO/STATION NO. <br /> Owner's Well No.Al .tff� — E±� �� No �4fi539 <br /> Date«'ork Began } ft,°r� ,i LATITUDE <br /> � ];'77dL'd � I LONGITUDE <br /> Local Permit Agency; <br /> �r <br /> .Permit No. rJ > � Pern0 Date /j/ �` '� � t APNITRS1CTHER <br /> GEOLOGIC LOG (cif" WELL OWNER <br /> ORIENTATION _VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Nalne <br /> DRILLINGx"fF € <br /> DEPTH FROM <br /> METHOD ' ta`.t t :r.1r. tl ;. Flailing Address �, 1'`. :-[•.•f'E;1'�'r' r ,4. •+` !~ _ <br /> a { -tt FLUID 3 I. <br /> r SURFACE l;a``` f f� DESCRIPTIO\ �L IA e", t, tt f <br /> FI. to Ft materi(rj, 1r(!1'1f SI C, calor, etc. CIN . - I. STATE ZIP <br /> M IVELL LOCATION <br /> Address , <br /> f f Cit�r <br /> { <br /> f" i 1(/ L-. ti'i. v�f;'�f'.F"1 ��- R✓..-4 a :. E i� y. a_ rF�J. f r=� <br /> cOLIntV rfy' IhC <br /> rf r r (' r'}-t't,. , .-a r.'f• - A,PN Book'' ! Pabe Parcel <br /> Toys°nsl�ip Ran <br /> Range Sectio <br /> Latitude €' I� I NORTH Longitude I I WEST <br /> DEG, MIN! SEC. DEG. MIN, SEC, <br /> LOCATION SKETCII ACTIVITY f ) <br /> i} NORTH NEW WELL <br /> f 9 li MODIFICATIONfREPAIR <br /> I Deepen <br /> !-N Other(Spenify) <br /> E .00 <br /> I I a T � CESTROY(Describe <br /> Procedures and Malenais <br /> _4� F Under"GEOLOGIC LOG') <br /> t.. C PLANNED USES (.�L) <br /> i <br /> I I WATER SUPPLY <br /> Domestic Public <br /> I Irrigation Industrial <br /> on <br /> I I L w MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> 1. HEAT EXCHANGE <br /> I r I <br /> r DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I <br /> SPARGING— <br /> I I .I SOUTH ' <br /> I} REMEDIATION <br /> Iltirxtr77ir!nr Dbtvribc Distmicr.of fi'c1l�mni Hoarls,13ui1din�s, <br /> I I - <br /> Fences.Ricers?etr, rrnfl d#rich n�+Inj}. Use rrdditianal 11�aper if OTHER(SPECIFY) <br /> necessary.PLEASE RE ACCURATE&COAfPLETF,. <br /> I I <br /> FVATER LEVEL & YIELD OF COMPLETE] R'ELL <br /> �} <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL y (Ft.)&DATE MEASURED <br /> I ESTIMATED YIELD ' I (GPM) & TEST TYPE <br /> TOTAL DE PTH OF 13011ING (Feet) TEST LENGTH li (Hrs_)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED 1FELI. (Feet) *May not lie i-ep7-ese1ntatizc of a well's 19);g-teiwi yield. <br /> DEPTH CASING (S) j DEPTH ANNULAR MATERIAL <br /> BORE- TYPE(—) I TYPE <br /> FROM SURFACE HOLE FROM SURFACE <br /> DIA. Y a MATERIAL I INTERNAL GAUGE SLOT SfZE OE- REN. <br /> (Inches) a Q o� GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m 0 05 (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE} <br /> uD o <br /> I r i I <br /> Il <br /> r <br /> 11TTACHME\TS l) CERTIFICATION STATEMENT <br /> }j I,the undersigned,certify that this report is complete Ilnd accurate to the best of my knowledge and belief. <br /> Geologic Log_ 1 <br /> .. Well Construction Diagram NAME__U� <br /> Geophysical Log(s) <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTEDI <br /> ,n i r <br /> SoillWate�Chemical Analyses �� A <br /> ' :A _- 5 q fsY <br /> Other { et a ADDRESS �� }!I CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, 1F IT EXISTS. Signed T <br /> LERlAUTHDRIZED R£PRESENTATiVE I q DATE SIGNED C-571ICENSE NUMBER <br /> + !h <br /> utrx Iso era ilei IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> F <br />