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0RIGINA,L STATE OF�CA�L+IIF/O�RNIA�j �]/� DWR USE ONLY — DO NOT FILL IN —� <br /> File %krill'} D R Tr ELI L 'iONIPLE f`lT'N REPORT I <br /> PagOE6f� y Rr.Fal' to In Pamphlet STATE WELL NOJSTATION NO, <br /> Owner's Well 1\O. _ No.749437 <br /> Date Work Began. ��- � Ended �— -"��' LATITUDE ElLONGITUDE [I <br /> Local Permit Aaenev (« � } j� <br /> Perinit \o. Permit bate APNITRSfOTHER <br /> GEOLOGIC LOG G♦'ELL O i'NER <br /> ORiEN T ATION VERICAL _HORIZONTAL —ANGLE —(SPECIFY) Narn ? ? ?! <br /> DRILLING r t <br /> METHOD FLUID - 'Mani Q�.'A.dF1Te55: . <br /> DEPTH FROM o <br /> SURFACE DESCRIPTION, 1.0 <br /> ... Ft. to FL Describe inaterial, grain .size, color, ete.t,• - n?r.�S ST, IP <br /> LOC T ON <br /> " Address C" <br /> ` �� •�AP`I\T Boo): Pa e <br /> Parcel <br /> �' TDwrisliipRange Section <br /> E 1 .� •`' + ' tifude .._ YI NORTH Longitude i i WEST <br /> DEG. MIN. SEC DEG. MIN. SEC. <br /> 1 LOCATION SKETCH 7ITY — <br /> _ NORTH ✓_ NEW WELL <br /> MOD)FICATl eEPAIR <br /> Deepen <br /> 1A." — Other(Specify) <br /> r. <br /> ,. DESTROY(Describe <br /> Procedures and Materials <br /> E _ E Under"GEOLOGIC LOG") <br /> PLANNED USES (4) <br /> I I - <br /> WATER SUPPLY <br /> E E - Domestic _ Public <br /> t E - Irrigation _ industrial <br /> LU rn <br /> I 1 $ w MONITORING _ <br /> TEST WELL <br /> E CATHODIC PROTECTION <br /> I 1 HEAT EXCHANGE <br /> I E DIRECT PUSH _ <br /> E E INJECTION <br /> VAPOR EXTRACTION <br /> I <br /> SPARGING <br /> I I - SOUTH REMEDIATION _ <br /> Illustrate or Describe Distance of Well roln Roads,BuilC hws <br /> t E Fences,Ricers,etc.antl attach ri map.Use additiortn2 ppaper of OTHER(SPECIFY) _ <br /> necessary.PLEASE BE ACCURATE&COJI[PLETE. <br /> 1 I <br /> E I - WATER LEVEL & FIELD OF COA-IPLETED WELL <br /> E 1 DEPTH TO FIRST WATER (Ft,) BELOW SURFACE <br /> I E DEPTH OF STATIC ' <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> E I <br /> ESTIMATI=D YEELD (GPM) &TEST TYP <br /> TOT?LL J)EIYFH OF BORING {�) TEST LENGTH {Hrs.)TOTAL DRAWDOWN <br /> (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "Mey not be representative of a zvsR! long-term yield. <br /> DEPTH BORE- DEPTH CASING (S) ANNULAR MATERIAL <br /> FROM SURFACE <br /> HOLE TYPE() FROM SURFACE <br /> DIA. Y a MATERIAL! INTERNAL GAUGE SLOT SIZE TYi7E <br /> (Inches) z ¢ �r a GRADE DIAMETER OR WALL 1F ANY CE- BEN- <br /> fit. to Ft. m U U rL DIAM(inchesETER <br /> TRICKINESS (inches) F1. to Fl. MENT TONITE FILL FILTER PACK <br /> f� c' (1) (I) (1) {TYPiESIZE) <br /> 1 '.V, ` <br /> 59 "2 <br /> TACI-TI+IENTS CERTIFICATION STATENIENT <br /> eologic Log 1, the undersigned, certify that this report Ip complete and accurate to the best of my knowledge and belief. <br /> 1 <br /> Wall Conslruclicn Diagram NAME _ra n i151t �;i/�� Inc <br /> ( - SON, FIRt}, OR CORPORAT ON) 1T'lPED DRP NTED) f <br /> Geophysical Log(S) -��_t � <br /> UGS 2 <br /> oliMaaler tlemiyal Analyses � u r <br /> ADDRESS '~ Crrl <br /> Other t _ } STATE_ TIP <br /> �+TACI-1 ADDITIONAL INFORMATION, !F IT EXISTS. Signed j J j [,S' i A F''(J <br /> WELL FfRlLLERlAUTNDRIZED RESEN TINE DATE SIGNED �_7 UCEt;SE NDL1BER <br /> rnti'tI 1134 Rrt' 1197 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />