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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY <br /> File with DW-;R — Do NOT Fru IN <br /> �x'ET L CJIPLEION REPORT <br /> Page O{ 'TRefer !o Insfrnction Pnothhlet STATE WELL NO./STATION N0, <br /> 0-ner's Well No Ido. <br /> Date work Began a ti Ended nom- 749433 <br /> LAriruDE LONGiruoE <br /> Local Permit Agen.ev - l <br /> Permit No. `� Permit Date — APNITRGlOTHER <br /> GEOLOGIC LOG 1�7Ej OWNER <br /> GRIENTATION {✓} VERTICAL HORIZONTAL — `(SPECIFY) l�?&ine �e(r <br /> DRILLING ANGLE 4 <br /> METHOD 1±' t�L114 Maila g Ad_t�ress. <br /> DEPTH FRDtws FLUID,`, <br /> SURFACE DF,SCRIPTIO�t _ �� y ^, ,^" �- <br /> FL ro FL Describe materi(II, hrnin. .size. cnZor, etG.�• _C STATE ZIP <br /> ^,� `1:'LL LOCFATION <br /> ACh.Ce55 <br /> � - `.�-•,•- NO �. A '.��"OLlll-tV� r'yl <br /> A• N Book Fame Parcel <br /> 14 '` Township. Range Section <br /> NORTH LongitudeI I WEST <br /> DEG. MIN. SEC. DEG, M1N, SEC. <br /> LOCATION SKETCH 'FI17ITY (,j�) — <br /> ' NORTH <br /> NEW WELL <br /> I - - MODIFICATipNJREPAIR <br /> 1 '- — Deepen <br /> r q Other(Spec+ly) <br /> r i r7 DESTROY(Describe <br /> Procedures and Malerrials <br /> r •i, - Under"GEOLOGIC LOG") <br /> PLANNED TTSES (�) <br /> WATER SUPPLY <br /> r r — Domestic Puhiic <br /> r r o — Irrigation Industrial <br /> LL, <br /> I r w MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION— <br /> r I HEAT EXC!i4NGE <br /> I 1 <br /> DIRECT PUSH <br /> r INJECTION <br /> I VAPOn EXTRACTION <br /> SOUTH — <br /> SPARGING — <br /> r I <br /> 111nstrnte nr Describe Distance of 1VeR f orn Road Buildings REMEDIATION— <br /> Fene(n,Ricers,etc.and attach a mrrp U.se additinnn2}}�aper if OTHER(SPECIFY) <br /> r necesaarY.PLEASE BE ACCURATE&co a"PLE'TE. <br /> NATER LEVEL & YIELD OF CONIPLCTED WELL I <br /> DEPTH TO FIRST WATER -- (Ft.) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> r I WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) d TEST TYP <br /> TOTAL DEPT II OF BORING (Feet) TEST LENGTH (Hes,)TOTAL DRAWDOW <br /> TOTAL DEPTH OF COAMLETED WELL �� (Feet} t`L----- <br /> May rant be re.Presetntative of a wells Ian,term yield. <br /> a <br /> DEPTH SORE- CASING (S) <br /> FROMSURFACE TYPE[} DEPTH ANNULAR MATERIAL <br /> HOLE FROM SURFACE <br /> DIA. w *,O'CMATERIAL INTERNAL GAUGE SLOT SIZE TYPE <br /> FI to <br /> Ft (Inches) ¢ DIAMETER OR WALL IF ANY CE. BEN- <br /> Ft. m (Inches) THICKNESS (Inches] R. to FL MENT TONITE FILL FILTER PACK <br /> (.::L (TYPFJSfZE) <br /> s <br /> 15 Z_ <br /> _ <br /> r <br /> r I <br /> r CACHNIENTS { j CERTIFICATIOT STATEMENT <br /> i, <br /> eologic Log the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> , <br /> Well Construction Diagram NAME <br /> Geophysical Logs) (PERSON, FIRIl OR C08FORATION} (TYPED OR PRINTED) <br /> Soilwater Chergical Analyses �(/'} y ) f <br /> �Othe�, ADORES CITYc� <br /> STATE ZIp <br /> A7TApN ADDITIONAL INFORMATION, 1F 1T EXISTS. Signe <br /> WELL DRILLE Af1TH IZE REPRESEMATNE pA?E SI�NEp <br /> C-5T LICENSE NUrA9ER <br /> nr'R ISx IIP It J- IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />