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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL. IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page �^ Refer to Instruction Pamphlet <br /> STATE WELL NO/STATION NO <br /> Pa a <br /> ofj-- � I_I No 0933086 <br /> Owner's Well No 1} t {J <br /> 111111 <br /> Date Work Began I.- Ended �-}'a'D LATITUDE LONGITUDE <br /> 01 Permit A�en(.y ?A t" �L�s �I I.i.rr MYIV fG,�1,J1 �� +�"' APNITRS/OTHER <br /> Permit No Permit Date' <br /> GEOLOGIC LOG `�F f QE L OWNER <br /> ORIENTATION ( �) i' VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Nam ��IQ'��1 L t"'�k(d \(.,,I r K' <br /> DRILLING f Nlail' ACldress y <br /> METHOD r ' lnW , �T.0 FLUID '- � 1�ti / ` r� <br /> DEPTH FROM ,•• f s, ��� ��,,� L.� 55 <br /> SURFACE DESCRIPTION L 1 <br /> Ft to Ft Describe material grain size color etc r� CI E STATE ZIP <br /> WELL LOCATION <br /> "(•^..Address I1 30 ` �� '.i rY1waj <br /> L Yl Tkl/>' { �f 3�/f ",11: �3G Y --I' ,f <br /> I t � \t C � ���OII71•Cyr��GLV�,r ���'9 'L�� <br /> �APN Book 1 Page Parcel <br /> N N \-"5 'Z'ownghlp % Range Section <br /> (_I at ' => I N Long I w <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH pT(�TIVITY i <br /> NORTH NEW WELL <br /> MODIFICATIONIREPAIR <br /> Sze- �'^ �� — Deepen <br /> _ Other(Specify) <br /> � <br /> DESTROY(Describe <br /> Procedures <br /> Under GEOLOGICrLOG) <br /> USES (') <br /> �X,1 1 WATER Si <br /> Domestic — Public <br /> I I w Irrigation — Industrial <br /> I € LU W MONITORING <br /> t I <br /> TEST WELL— <br /> t CATHODIC PROTECTION — <br /> HEAT EXCHANGE— <br /> DIRECT PUSH — <br /> I I INJECTION — <br /> t I VAPOR EXTRACTION — <br /> t SPARGING — <br /> SOUTH REMEDIATION T <br /> IIlustrate or Describe Distance cf Well from Roads Buildings OTHER(SPECIFY) <br /> Fences Rxers etc and attach a map Use addazona2 paper t ) — <br /> necessarl PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> t I <br /> i DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING Z (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representative of a well's lint -term yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(—') FROM SURFACE TYPE <br /> DIA Y z to a MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> w n FILTER PACK <br /> (inches) oU a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to Ft m c� c» (Inches) TH)CKNESS (Inches) Ft to Ft (TYPESIZE) <br /> PVL5jA Ltd LZ 3 i/ <br /> t ' S <br /> I <br /> i <br /> I <br /> ATTACHMENTS ii CERTIFICATION STATEMENT <br /> the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geologic Lag r <br /> muWell Construction Diagram NAME 4S ' 3 ��y1� ' <br /> {PERSON FIRM OR CORPORATION) (TYPES OR PRINTED) <br /> Geophysical Log(s) , Qr <br /> _`SoIUWater Chemical Analyses 33_)� A <br /> 'Ot A1kM ADDRESS _ CITY ``��yy STATE q ZIP <br /> Other. s SIL-AW <br /> '�- 1-I`Signed <br /> ATTACH ADDITIONAL INFORMATION 1F fT EXISTS C 57 LICENSED WATER WE L CONTRACT R PATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 05 03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />