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ORIGINAL SLATE OF CALIFORNIADWR USE ONLY — DO NOT FILL !N <br /> File with DWR WELL COMPLETION REPORT <br /> Page of Refer to Instruction Pamphlet STATE WELL NO!STATION NO <br /> Owner's Well NoNo 0933087 <br /> LATITUDE LONGITUDE <br /> Date Work Began�-1�i--I:l�i ended `��}- -- -.-.- <br /> coal Permit A enc S°� � ��v� GvJ.V F.1y,'cf1 tt�'a.i�� p <br /> j Y r_ APNITRSIOTHER <br /> Permit No j y6 Permit Dater <br /> GEOLOGIC LOG �s ��VE L ffO,�W_ NER <br /> ORIENTATION (�) VERTICAL HORIZONTAL ANGLE —(SPECIFY) Nam ` T (r`ch {-tt,L _ L'4� `� <br /> DRILLINGtx <br /> METHDID - FLUID �Nlaihn Address <br /> osuRacEM W\ �'`t 'r '�SCR 0 DEs -' �� a� <br /> Ft to Ft Describe matertttl grain size, color etc 1 "� L�,/'� ` ,: STATE ZIP <br /> WELL LOCION <br /> Aad�Ess � .�, A�' <br /> y 1 1 <br /> . � <br /> I I &14V�,WgX <br /> C� Gt t. �� rt e' County =4 t, <br /> 5 j i Cl c c " "`- �� -�APN Book Page Parcel <br /> Township " = Range SeCt1OD <br /> 1 N Long W <br /> DEG MIN SEC DEG MIN SEC <br /> ,cam LOCATION SKETCH TIVITY i <br /> NORTH ter NEW WELL <br /> i i �,.`~ , 1 /1� ✓ MODIFICATIONIREPAIR <br /> 'Stk 61 Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> r Procedures and Materials <br /> Under GEOLOGIC LOG J <br /> USES (:�.) <br /> WATER SUPPLY <br /> Domestic — Public <br /> I I Irrigation _ Industria <br /> r ¢ MONITORING <br /> I I TEST WELL— <br /> CATHODIC PROTECTION _ <br /> I I <br /> HEAT EXCHANGE <br /> gIRECT PUSH <br /> INJECTION <br /> I I VAPOR EXTRACTION _ <br /> i I SPARGING — <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roods Buddtngs <br /> i I PenceS Rlt.ers etc and attach a map Use ad[Iihonal pneer iy OTHER(SPECIFY) ..__. <br /> necessarf PLEASE BE ACCURATE&COb1PLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 1 <br /> DEPTH TO FVRST WATER (Ft) BELOW SURFACE <br /> I I <br /> i I DEPTH OF STATICi <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> I i ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL __(Feet) May not be representative of a well's long-term yield <br /> DEPTH BORE <br /> CASING (S) DEPTH ANNULAR MATERIAL FROM SURFACE HOLE TYPE(�) FROM SURFACE TYPE <br /> DIA z "i MATERIAL t INTERNAL GAUGE SLOT SIZE CE SEN <br /> W o ° FILTER PACK <br /> (Inches) w zw a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to Ft u �O j (Inches) THICKNESS (triches) Ft to F1 (TYPElSIZE) <br /> n o C�- <br /> 0 �2 t� v Yc <br /> 3 Lv 3rkMl H 3io <br /> i <br /> i r <br /> I I <br /> ATTACHMENTS i CERTIFICATION STATEMENT <br /> I the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geologic Log 1 <br /> _ Well Construction Diagram NAME �� i w •"'�' <br /> (PERSON FIRM DR CORPORATION) <br /> (TYPED OR PRINTED) <br /> _ <br /> Geophysical Logs) RAY, 43i�� Gim& P �! i / <br /> Gh ` 1 4. <br /> SoillWater Chemical AnalysesCITY STATE ZIP <br /> 1 ADDRESS(l,i iI�''��'J} <br /> ATTACH ADDITIONAL INFORMATION 1F IT EXISTS Signed"�S��ENSEO TER ELL CONTRACTOR Oq 4 ,'��l ^ DATE SIGNED �57 DENSE NUMBER <br /> DwIl Iss REV 0503 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM DSP 03 78836 <br />