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ORIGINAL. STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File ilLrlth DWR NVELL COMPLETION REPORT I I <br /> .va"e n£ Hefrr to Instruction Pmnp7elrt STATE WELL NO.ISTATION NO. <br /> Qr<'ner's �ireIl No. TLj � <br /> "°-74943El <br /> Date Work Began <br /> ` Ended. LATITUDE LonlclruDE <br /> LoCal Permit Anency _;;.. �• � ^ <br /> Permit �O. Permit Date - - "'!ry�z APNITRS/OTHER <br /> GEOLOGIC LOG <br /> ORIENTATION (7} VERTIgAL —HORiZONTAL —ANGLE —(SPECIFY) Nai71C - <br /> DRILLINGs <br /> DEPTH FROM METHOD j ` FLUID Mailing- C1 he!, <br /> SURFACE DESCRIP ION _n , �1. t ,,�' '.� rA <br /> Ft. to FL Describe 7nateTial, greiin size, calor, etc,', -CITYt- ,,.-� ` �� STATE ZIP <br /> ti «' LOCA BION <br /> Ad'clre s <br /> c" County <br /> F{ ALT` Boal ane Parcel <br /> .Tov-i s, ip Ranl-e Section <br /> atltude f NORTH I.,OI1bltude I I WEST <br /> �' •� � -*° DEG. MIN. SEC. DEG. MIN SEC. <br /> LOCATION SKETCH rA VITY (!) -- <br /> ' P��'' <br /> NORTH <br /> I ^- NEw wEL4 <br /> MODIFSCATIONIREPAIR <br /> C Deepen <br /> `1'1 + Other(Specify) <br /> DESTROY(Describe <br /> I I Procedures and Materials <br /> Under"GEOLOGIC LOG" <br /> r i - <br /> PLANNED USES () <br /> WATER SUPPLY <br /> t i <br /> Domestic Public <br /> F lrrigaCon �. Indistnal <br /> w rn <br /> - }s W MONITORING <br /> I <br /> TEST WELL <br /> F I CATHODIC PROTECTION_ <br /> r I HEAT EXCHANGE_ <br /> r I DIRECT PUSIi <br /> i iNJECTION <br /> VAPOR EXTRACTION_ <br /> I I <br /> SPARGING_ <br /> a I SOUTH REMEDIATION <br /> 1117simte or Describe Distance of Well from Rnada,Biritdina�s�} <br /> Fences,Ricers,etc.and attach a neap. Use arlr2itinnal ppa)5er I OTHER(SPECIFY) <br /> necessanj.PLEASE BE ACCURATE cs COdiPLETE. <br /> I 1 <br /> WATER LEVET, Fi YIELD OF COMPLETED WELL <br /> I I OEPTH TO FIRST WATER'S (Ft.) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (Fq&DATE MEASURED <br /> I I ter. <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE_ <br /> TOTAL DEPTH OF BORING ; (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWPL_�{Ft. <br /> TOTAL DEPTII OF COMPLETED NPELL n,!L Feet) '-1way not be reprcrenWrive of a ivell�s long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> )"ROM SURFACE HOLE TYPE(—') FROM SURFACE <br /> DIA. z o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE, REN- TYPE <br /> (inches) z Qa- a GRADE DIAMETER OR WALL IF ANY <br /> MENT TONTTE FILL FILTER PACK <br /> Ft. to `ri. m c> U`I Inches THICKNESS <br /> y o (inches) (Inches) Ft. to 'rt. (�) (�) (✓) {TYPEISIZE) <br /> e} L Q It{ <br /> � �!i•i I <br /> e6sl <br /> �V,,ATTACf;\IENTS CERTIFICATION STATEMENT <br /> I, the undersigned, certify that this r is complete and ccurate to the best of my knowledge and belief. <br /> deoiogic Log .q�1f d � <br /> ell"onstrtfction Diagram NAME M F I fiwtliltl'm .5d d 4 i r <br /> SPERSDN, FIRM. OR CORPORATION) )TYPED 0 INIED)� -` <br /> �. Geophysical Logs) �J r <br /> alVNlaterG emica•Analyses r - ✓U' t <br /> Cher fir' ADDRESS CITY <br /> O <br /> j <br /> ,� STATE IIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT!<X1STS. Signed ` W7/4 .tel tF 4_0 ��-7 <br /> WEiL DRILLFRIAD4ORiZR PRESENTATIVE <br /> DRILLIERIARDA7F SIGNED C•5) LICENSE N.T13ER <br /> RF.%' r)-:; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />