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ORIGINAL STATE OF CALIFOR\IA DWR USE ONLY — DO NOT FILL. IN -- <br /> I File With DWR WELL COMPLETION REPORT Fill 111 111111 <br /> Page 1 of I Refer to Instruchnn Paf iddet STATE WELL NO/STATION NO <br /> Owner's Well No m No <br /> 822129 <br /> I Date Work Began 71 VG14 Ended saror. LATITUDE LONGITUDE <br /> Local Permit Agency SAM^ � ,vin r,;:ittr iklm!.OLA 10, ✓"Sr`un <br /> Permit No 81 Permit Date 5�/l�q9 APNlTRSlOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> Fie,4Kt- <br /> DRILLINGMailing Address O Op g <br /> DEPTH FROM METTHODHOD FLUID � ess <br /> SURFACE DESCRIPTION Et. sm"AA _2 7 <br /> I Ft to Ft Dt scribe matLrial -rain vi..c color etc CITY STATE ZIP I <br /> FELL LOCATIO <br /> ' Address <br /> City non+eco — - <br /> I County_ _So,^ ZI-00"IL'r^ <br /> APN Book tcl ik Page 17 Parcel 006 <br /> ' To-vnsh Banc, Section <br /> Litittide I I NORTH Longitude I f WEST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVIT2 (z�) <br /> I I NORTH — NEW WELL <br /> I <br /> MO DI FIC AT[ONIREPAIR <br /> I i Deepen <br /> i I <br /> — Other(Speclly) <br /> le-I i Qi <br /> DESTROY(Describe <br /> I t i Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> PLANNED USES (—') <br /> I r WATER SUPPLY <br /> i5tI11 <br /> I � Domestic Public <br /> Irrigation Industrial <br /> I Lu rA <br /> w MONITORING - <br /> I r TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> F•�'�}`-� DIRECT PUSH <br /> INJECTION _ <br /> ' ' ov. t f�s� � ���` VAPOR EXTRACTION_ <br /> t I SPARGING_ ! <br /> I r SOUTH REMEDIATION_ <br /> IRrrstrat(nr UtserdA Uwarja of 11411 Froin Rowels Ruddnl"s <br /> I I Fences Rrt.ers etc and rinach a IIIntt� Isc addihnnn!++rrr)rr r f OTHER(SPECIFY) f <br /> neccssanj PLFASE RE ACCURATE&COUP L£TE <br /> NATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> f r DEPTH TO FIRST WATER {Ft} BELOW SURFACE <br /> i DEPTH OF STATIC <br /> WATER LEVEL 1---- (Ft)&DATE MEASURED 7/S--/aq <br /> 1 t F <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN ,Y (Ft) <br /> TOTAL DEPTII OF COMPLETED M ELL (Feet) 'May not he rept eaentative of a uell's long-tern }rrld <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(—' ) FROM SURFACE TYPE <br /> DIA x = ¢ a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> TYPESIZE Ft to <br /> Ft to Ft m V U� � {Incomes} THICKNESS {Inches( Ft ( ) <br /> (9Pvc. sc. .' qD o.o-D 0 ' 3 <br /> S 2< >ytoo 3 <br /> ' 2 <br /> 1 I <br /> I <br /> I r <br /> I ATTACHMENTS CERTIFICATION STATEIIENT <br /> Geologic Log f the undersigned certify that this report IS complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME VLL, r't lY�t <br /> {PERSON FIRM-41R (TYPND OR PRINTED) <br /> — Geophysical Log(s) co `� d y�� <br /> _.._.. Soti/VJater Chemical Analyses �� �'� I� 0. CJT <br /> — Other ADDRESS Or 1-4 CITY 1 STATE ZIP <br /> ATTACH AOblOt her. INFORMATION IF IT EXISTS Signed '�✓ y ~ q I �I a <br /> I WELL DRILLfR/APTHORIZED REPRESENTATIVE DATLI SIGNEY C 57 LICENSE NUMBER <br /> 1W It ISS R 1 li sr IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />