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ORIGINAL STAT OF•TC'ALL1TF'!OR\IA�j REPORT <br /> OWR USE ONLY — DO N17 F}LL SN <br /> File with L�WR t7C EI-IL vQ�iPLFu' i 7�O R POR iI I II i <br /> Page i—ofj— � 73rfer to Tnstriirtidn pemipl,ICt STATE WELL NO./STATION NO. <br /> 0% per's Well NO. '�ilv� No. <br /> 749437 <br /> Lj <br /> . Date Work Begat?� "Q End,d �'� -''�V LATITUDE ❑ LONGFTUDE ❑ <br /> Local Permit Agency � } PI <br /> 9 �, APN/TRS/OTHER <br /> Permit Na..i7�F Permit Date <br /> +�t <br /> GEOLOGIC Loc a�ELl o VNFR <br /> CRIENTATION (✓} VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) NaT.n - <br /> DRILLING <br /> DEPTH FROM <br /> METHOD FLUID -Niaili g'Address y <br /> SURFACE DESCRIPTION <br /> ;L to Ft. DL'S CrIbC ?UatCrial, gr(llil Size, G0101% QtC.. � CIJ-�., /'•; i ,k � STATE ZIP <br /> "'L LOC TON <br /> •'�lt<r) <br /> CDunty, i <br /> -, APN Book <br /> Pap Parcel <br /> t`~ fTovriiskip Range Section <br /> ' .Latitude NORTH <br /> _ e I I 1�OFtslitUCle I I WEST <br /> r,.i `• l` ;r REG, M W. SEC. b DEG. MIN. SEC. <br /> LOCATION SKETCH AAIVITY <br /> NORTH NEW WELL <br /> MO1D€FICATfON1REPAIR <br /> Daepen <br /> — Other(SpecHy) <br /> DESTROY(Describe <br /> r I Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> I , . <br /> PLANNED USES (�} <br /> WATER SUPPLY <br /> Domestic Public <br /> I I N Irrigation In,tusinal <br /> ul N <br /> w MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> I I DIRECT PUSH <br /> t I INJECTION LZ <br /> t i <br /> VAPOR EXTRACTION_ <br /> I I SOUTH SPARGtNG_ <br /> Illustrate or DeSCribe Distance of Nell1frant Roa(s,BuiIdtngs REM`-DIAMON <br /> I I Fences,Rit3ers,efe.and attacli a njap. Use rrdrlitional aper i� OTHER(5PECtFY) <br /> I I <br /> necCssanj-PLEASE BE ACCURATE i&CD].,, . <br /> WATER LEVEL &- YIELD OF CON1PLETED AVELL <br /> t I DEPTH TO FIRST WATER ',., ) (Ft) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> I WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD' (GPM) & TEST TYPE­—, <br /> TOTAL I]ElrfH OF BORINGESTIMATED <br /> LENGTH (Hm)TOTAL DRAWDOWN <br /> TOTAL DEPTH OF COMPLETED WELL (feet) *Afay not be representative of a well's long-term yield. <br /> DEPTH _ CASING (S) <br /> FROM SURFACE BORE TYPE{�) DEPTH ANNULAR MATERIAL <br /> HOLE FROM SURFACE <br /> TYPE <br /> IIA. Z w ,o MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN. <br /> Ft. to Ft. (Inches) w¢ I- GRADE DIAMETER OR WALL IF ANY MENT TON€TE FIL{. FILTER PACK <br /> inches THICKNESS (�) (^) (-1)✓} (TYPElSIZE) <br /> m m L) = ( } (Inches) Ft. to Ft. <br /> �r <br /> Fboo <br /> I <br /> I <br /> I I <br /> "fACHMENTS <br /> CERTIFICATJON STATEAiENT <br /> i, the undersigned,certify that this report i complete and accurate to the best of my knowledge and belief. <br /> eDlogic Log Jj <br /> Well Construction Diagram �t` A <br /> Geophysical Log(s) <br /> f SON, FIRI.T, DR CORPORAT ONI (TYPED DR P NTED <br /> oll/water hemf�al Analyses 3�3 ' [C. r. I�e f t ,yJ R `/7b <br /> Cher f ADDRESS <br /> --` CIT!' Pf STATE_ ZIP <br /> ATTACH ADDITIONAL INFOAMATION, IP 17 EXISTS, Signed - 1 I(C.�+,r- + 3� '"1� p <br /> l7ELL DRILtERlAUT;LORItED RESENT€'fE DAZE SIGNED C-51 LI..EIaSE NUI.tRER <br /> DWR IRti Rr.", I1.417 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />