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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL iN <br />' File with DWR WELL COMPLETION REPORT <br /> Page_L,_of- I t3tfer to bmirtuctum Paiulihlet STATE WELL NOISTATION NO <br /> _ /y�f.I <br /> 0-wrie.r'S Well No /ILS. NO 822131 LATITUDE ❑ LONGITUDE ❑ <br /> Date N1'oi 7 k Began /&5/qui Ended SOVA e• <br /> Local Permit Agencv so^ cct ✓gin Env- ei:4 Hk 0,-v. <br /> Perinit No Uiq Q s�//�q�1 Peinut Date APNfT lsroTHER <br /> GEOLOGIC LOG NVELL ONS NER <br /> ORIENTATION (✓) —VERTICAL _HOMZONTAL —ANGLE —(SPECIFY) Name F AO"' <br /> DRILLINGP� Q X I QQ L�g <br /> DEPTH FROM METHOD FLUID Mailing Addre55 - - - <br /> SURFACE DESCRIPTION ,rn A2_ <br /> I Ft to Ft Describe maty real grain size color LtG CITY STATE ZIP <br /> r 1 <br /> } <br /> / 1111E LOCA 101 <br /> Address 4 l kv S <br /> I I Cit`✓ /�1,01 4op, <br /> I I b n WGl rG�fvrL County ser., TD«Gturk+ <br /> ` APN Book 129 Pagc V/7 Parccl <br /> ' 7bamslup Range Section <br /> Latittide I I _NORTH Longitude I I WEST <br /> DEG MIN SEC DEG MIN SEG <br /> LOCATION SKETCH ACTIN ITI (�) <br /> I I NORTH NEW WELL <br /> f <br /> �+ MODIFIGATIONlREPAIR <br /> Deepen <br /> I Other(Specify) <br /> I I <br /> e I <br /> r DESTROY(Describe— <br /> :24-A-7 r1(j!-3 Procedures and Materoals <br /> Linder GEOLOGIC LOG) <br /> PLANNED USES t ) <br /> i WATER SUPPLY <br /> DDMCStIC Public <br /> Irrigation Intlus[ual <br /> I I ILL! t¢ MONITORING <br /> lot K I I lq TEST WELL <br /> to CATHOMC PROTECTION_ <br /> HEAT EXCHANGE _ <br /> I I <br /> DIRECT PUSH <br /> INJECTION <br /> I <br /> VAPOR EXTRACTION <br /> Arc- SPARGING <br /> SOUTH REMEDIATION <br /> 111mliate or De scrrbc Drstaeiee if it e/I(mini Rands Buddrns <br /> i <br /> Fences Rue rs etc and niiaeh a alar Use rrrlrhrruriaP 1ialir r f OTHER(SPECIFY) <br /> lieressand PI EASE BE ACCURATE&C011PI FTE <br /> 1 I <br /> AVATER LEA EL & YIELD OF COSIPLETED TELL <br /> DEPTH TO FIRST WATER 1( _ (Ft) BELOW SURFACE <br /> DEPTH OF STATIC It <br /> WATER LEVEL _(Fit&DATE MEASURED 7/ <br /> i I ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORINC {Fc Lt) TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft I <br /> TOTAL DI PTII OF COMPLETED NVFLL (Feet) 'Way not he 9epiestrinatize Of a veil's long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR NIATERIAL <br /> FROM SURFACE BORE HOLE TYPE(2!� FROM SURFACE TYPE <br /> ) <br /> DIA Y w p a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) z �r `a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m U o= - (inches) THICKNESS {Inches) Ft to Ft L (TYPE SIZE) <br /> - sc1,-qD © 3 <br /> .020 i <br /> I I <br /> I I 1 <br /> I r <br /> I ATTACHMENTS (z�) CERTIFICATION STATEMENT <br /> I the undersigned certify that this report is complete and accurate to the best of my knowledge and belief <br /> — Geologic Log ++ J � <br /> Well Construction Diagram NAME ���JCJI,4 / IQ K _� �x,0f0� �1�� 1�L <br /> (PERSON FIRM CORPORATION) (TYPED R PRINTED) <br /> — Geaphysscal Log(s) ,yam 3 C-le k \ CA 99sW,!�' <br /> — Soit/Water Chemical Analyses <br /> ADDRESS CITY �pSTATE ZIP <br /> — other 2-7f 1 L�:�l:�' <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> I WELL DRILL ATIVE DATE 9ONED C 51 LICENSE NUMBER <br /> SAI 11 1titi 111\ II+r- IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />