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ORtGtNAL. STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN ] <br /> Gila ;rThDI <br /> Al'l''R 11J T � <br /> PageOf I Refar to fnstrnrtion Pamphlet STATE WELL NO.ISTATION NO. <br /> � /"� No. <br /> 749435 ❑ ❑ <br /> Date M7oTk Began EriCle�dz <br /> • '`4 . LATIruDE LONcirunELocal Permit 10 .�lne_nc)r " ~' I <br /> Permit \o. Peranit late 1'7 L APN rR srOTHER <br /> GEOLOGIC LOG Ti'E L N'R <br /> C91ENTATION ( L) VERTII�,AL HORIZONTAL _ANGLE —(SPECIFY) NaITIL'� - 6`• '� �r "� <br /> DRILLING if <br /> .C dClreSs- <br /> METHOD Maill lfi <br /> DEPTH FROM � � FLUID <br /> an <br /> SURFACE DESCRIP IO\ �, ~ - s e. !'• °` {� <br /> DCScribc material, grain Sive, COZor, CtC.,. <br /> 'CIT , .� y ',�-�" STATE ZIP <br /> Ft. to Ft. -•' 1L 'LL LO ATION <br /> r <br /> `'_ Gotaiity` CA <br /> 'p,:1'�t BUak \ ar, Parcel <br /> TO'Attisl ip, Range Section <br /> ` r Y .6tUde 1 I NORTH Lon-,tude I I WEST <br /> • , ,` <br /> 1,ter'• <br /> DEG. MIN. SEC. b DEG. MIN SEC <br /> C " LOCATION SKETCH A `'ITI' (4) — <br /> NORTH NEW WELL <br /> i <br /> MODIFICATIONIREPAIR <br /> yl.. — Deepen ee k <br /> y c� _ Other(Specify) <br /> f <br /> DESTROY(Describe <br /> Procedures and Maleriels <br /> Under"GEOLOGIC COG" <br /> PLAN\TED USES (i�:) <br /> h. WATER SUPPLY <br /> Domestlt _ Public <br /> ' _ Irrigation _ Industrial <br /> H <br /> w MONITORING <br /> I 1 TEST WELL <br /> CATHODIC PROTECTkON <br /> HEAT EXCHANGE <br /> E I <br /> - I DIRECT PUSH <br /> INJECTION <br /> ' VAPOR EXTRACTION <br /> I I SPARGING <br /> i SOUTH REMEDIA71CN _ <br /> Illustrate or Describe Distance of Wall from Roads,Buildints, <br /> I t Fences.Rivers,etc.and attach a raapp. Use additional raper if OTHER(SPECIFY) <br /> necessartt.PLEASE BE ACCUTLATE 'v COMPLETE. <br /> { I <br /> WATER LE[ IELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER' (Ft.) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) & TEST TYPE w <br /> TOTAL DEPTH OF BORING ti (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN_(Ft.) <br /> TOTAL DEPT11 OF COMPLETED VIELL (Feet) May not be representative of a well's long-terms yield. <br /> DEPTH I CASING (S) DEPTH AN ULAR MATERIAL <br /> FROM SURFACE BORE-HOLE TYPE(:fl) FROM SURFACE TYPE <br /> D{A. x w d MATERkALI 19TERNAL GAUGE SLOT SIZE CE• REN <br /> (Inches) amu+ zo~ a GRADE DIAMETER OR WALL IF ANY MENT EE' FILL FILTER PACK <br /> Ft. 10 Ft. m v U (triches) THICKNESS (inches) Ft. to Ft. (TYPE/SIZE) <br /> ^'l V <br /> 1536 c <br />' ; 1 <br /> F--- -- TTACIfMENTS (zL) CERTIFICATIONSTATEMENT <br /> ® <br /> r I, the undersigned, certify that this r is complete an�ccurate to the best of my knowledge and belief.eologic LOU <br /> loll Construction Diagram NAME � t��t�1 �� <br /> (PERSON, FIRM, OR CORPORATION(Fa <br /> (TYPED OR PRINTED) <br /> Geophysical Log(s) r , <br /> blkMlaterC em)ca•Analyses <br /> ADDRESS T + CITY STATE ZIP <br /> Other s I o <br /> AT7AC-1 ADDITIONAL INFORMATION, IP IT EXISTS Signed `''�' <br /> WEtL DRILLERlAIf 6RIZ A PRESENTATIVE DATE SIGNED C-57 LICENSE N MBER <br /> OW11, 1>% IiiV IIJ07 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />