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! ORIGINAL STATE OF CALIFOENIA DWR USE ONLY — DO NOT FILL IN <br /> Pile with u.'vP$ 1:7ELL "OTNIPLETION RETORT <br /> Page .f # Rrfer to Iristrs.rciioly Prrntphlet STATE WELL NO.ISTATION N0. <br /> owner's Well No. ❑ <br /> []ate Work Began -t�I EndedA <br /> {1'� ° 749436 LATITUDE ❑ LONGITUDE <br /> . Local Permit Agency i w U <br /> Permit i�'o APNITRSIOTHER <br /> Peri tit Drte����, , <br /> GEOLOGIC LOG d�'E L V ER <br /> �/ <br /> ORIENTATION (�) VERTICAL �_F,iORIZONTAL ANGLE —. SPECIFY) Nartie st:NZ it� <br /> DRILLING , <br /> DEPTH FROM METHOD FLUID 'liltI o Addi'esl - 4 <br /> SURFACE DESCR PTION <br /> Ft. to Ft. Describe material, crai11 size, color, L't G. CIN;=,,f ' °S , •'• STATE ZIP <br /> r <br /> ATLI, LOCATII)N <br /> Addie" � . <br /> tAFN Book Pae Parcel <br /> i x .f Totiinlsliip.: '- Range <br /> I I Section <br /> "Latitude I I NORTH Longitude I I WEST <br /> DEG. M . SEC. DEG, MIN. SEC. <br /> LOCATION SKETCH rTTY (�) <br /> NORTH <br /> NEW WELL <br /> I � <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> DESTROY(Describe <br /> • I Procedures and Materials <br /> Under"GEOLOGIC LOG' <br /> i <br /> PLANNED USES (.�L) <br /> WATEPI SUPPLY <br /> I Domestic PubliC <br /> Irrigation IndUstrial <br /> LIP co <br /> 3 MONITORING <br /> LU <br /> TEST WELL <br /> CATHODIC PROTECTION_ <br /> HEAT EXCHANGE_ <br /> I DIRECT PUSH <br /> I i INJECTION <br /> I � <br /> VAPOP EXTRACTION <br /> SOUTH SPARGING <br /> Illustrate or Describe Distance of Wall fmm Ruatls,Buildinn REMEDIATION <br /> ' I fences,Rivers,etc.antl atim a nurrpp se additional ppopar if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE d;CObIPLGT,. <br /> I I <br /> WATER LEVEL &: YIELD OF CONIPLETED NVELL <br /> I I DEPTH TO FIRST WATER(Ft.) BELOW SURFACE <br /> I DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I _ <br /> ESTIMATED YIELD ' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING f (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN <br /> {Ft.) <br /> TOTAL DEPTH OF COMPLETED W LL (Feet) "May not be representative ofa well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(�) FROM SURFACE f,PE <br /> DSA. X w ¢ ;i MATERIAL! INTERNAL GAUGE SLOT SIZE <br /> Ft. (Inches) c pU GRADE DIAMETER OR WALL IF <br /> t0 Fl. CE- BEN- <br /> GRADE <br /> MENT TONITE FILL FUER PACK <br /> in U (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> 6;^' <br /> ^ V Y <br /> _ � y <br /> ------------- <br /> L <br /> ACHMENTS (z�) CERTIFICATION STATEMENT <br /> wI, the under igned, certify that this r p is compee a accurate to the best of my knowledge and belief. <br /> �eologic Log r1 lt <br /> i <br /> :,Construction Diacram NAME t b ! <br /> RSDN, RA, DR CoRPGRATIQNJ ITYPED R ANTED) <br /> Geophysical Log(s) 1-220 <br /> }� <br /> SoiI/VVater C emical Analyses `j �(.t o <br /> Oth?r Afl0RES5w <br /> r CRY STATE T3P <br /> ATTACH ADDITIONAL INFORM TION, IF IT EXISTS Signed Al ' Yf �� t jllfi <br /> ELL DPoLLERlAUTHQRI DRE DATE SIGNED C•57 LICENS NUkiBER <br /> J)NN'R ISs RPX 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />