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ORIGINAL STATE OF CALIFORNIACWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page_L_Of I Refer to Instructton Pamphlet STATE WELL NO/STATION NO <br /> Owner's weal No No 0931099 <br /> LATITUDE LONGITUDE <br /> Date Work Began r�'��-�: _ , Ended �'`«'UL 4 � {��}} {� <br /> cal Permit R enc s Od4,�t� ���' cq\Vt 3d",frYti rd �w1jL� D �, <br /> Y _ r_ APN/TRS/OTHER <br /> Permit No — Ll�a _Permit Date V <br /> GEOLOGIC LOG ,r (� �}}_`` E L OWNER <br /> ORIENTATION (:) VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) NamT ,,A'i4'� i��tI4 : `'A A f <br /> METWOD DRtLLIN �,� �� FLUID 1�Iaili❑ 'Address Y 'C ►, <br /> DEPTH FROM ,�, L r,/ C C D <br /> SURFACE DESCRI TION \�� '�� <br /> A. <br /> Ft to Ft Describe material, grain size color etc CIN\�� � � � �� STATE ZIP <br /> W LL LOCATION <br /> z/ d^ <br /> —Addre din W a <br /> In 1 E.. 1-i Y.,f r� r !1� j1 / � Coil LY\--kAlY\ l� <br /> Cot <br /> u t" +n <br /> j' rA Ad� v� -�APN BookPage Parcel <br /> y S 'Township = Range Section <br /> ✓' I I Loncr W <br /> I I r��^ .1 ✓ ,,4 ,R� ,�'� ,� r,.. DEG MIN SEC b DEG MIN SEC <br /> LOCA'T'ION SKETCH — A TIVITY (2L) <br /> NORTH <br /> EW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> Other(Specify) <br /> DESTROY(Describe rials <br /> Under CEOLOGfCrLOGPcedures and J <br /> USES OL) <br /> WATER SUPPLY <br /> Domestic _ PuWic <br /> I I Irrigation _ Industna <br /> I I LL ¢ MONITORING <br /> w <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE — <br /> DIRECT PUSH <br /> t <br /> INJECTION <br /> I I VAPOR EXTRACTION — <br /> SPARGING <br /> SOUTH REMEDIATION , <br /> Illustrate or Describe Distance of Well front Roads Buildings} <br /> Fences RILers etc and attach a mag Use additional paper 1 OTHER(SPECIFY) <br /> necessanf PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL' &p YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER 4 (Ft) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC 40 <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (R) <br /> TOTAL DEPTH OF COMPLETED WELL _C,2IL_(Feet) "May not be representative of a well's II yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BARE <br /> FROM SURFACE HOLE SPE(if�) FROM SURFACE TYPE <br /> DIA Y z t= a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BEN <br /> w o FILTER PACK <br /> (Inches} z zr a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft to Ft m v �.U�. (InrhQs) THICKNESS (lnrhel) Ft to Ft (TYPElSIZE) <br /> cu (—) , (—) <br /> I <br /> I <br /> L4 <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I, the undersl reed certify that this report Is complete and accurate to the best of my knowledge and billet <br /> Geologic Log r � <br /> -� <br /> Well Construction Diagram NAME: S�t <br /> ta <br /> FIRM OR C�OO�RRPORATION) (TYPED PRINTED) <br /> Geophysical Logs) r 3 r �r �dt4 �q� �''� '% <br /> _ SoilMlater Chemical Analyses 3 }< L <br /> tLy\ ADDRESS (/,�' CITY STATE ZIP <br /> Other . 1— StgrredJ 4 ofL rf —)-1 <br /> ATTACH ADDITIONAL INFORMATION 1F IT EXISTS C 57 LICENSED WATER ELL CONTRACTOR DATE SIGNED C 5] tIGENSE NOMBER <br /> D',VB 188 REV 0503 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />