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QUAD(UPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements ALL COMPLETION REPOR <br /> Page_of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. 0917818 <br /> Date Work Began 1';ncl�'tl _,� E — LATITUDE LONGITUDE <br /> Local Permit Agenc. <br /> Permit No. Permit bate APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (2:L) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING <br /> DEPTH FROM METHOD FLUID Mailing Addr'e'ss <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY STATE ZIP <br /> WELL LOCATION <br /> Address <br /> city <br /> County <br /> APN Book Page Parcel <br /> Township-X Range Section <br /> Lat I t 1 N bong W <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (2:L) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> _�,,.BIfSTROY(Describe <br /> Procedures and Materials <br /> - Under"GEOLOGIC LOG") <br /> USES(�) <br /> i i y WATER SUPPLY <br /> Domestic _ Public <br /> r.: <br /> _ Irrigation _ Industrial <br /> CD MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION_ <br /> HEAT EXCHANGE <br /> / DIRECT PUSH <br /> INJECTION— <br /> t <br /> - - – VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> Fences,Rivers,etc.and attach a map. Use additional paper if OTHER(SPECIFY) <br /> neeessan/.PLEASE BE ACCURATE&COMPLETE. <br /> � I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING a,t (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN <br /> �_(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL �, ' (Feet) "May not be representative of a well's long-terns yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL. <br /> FROM SURFACE BORE- <br /> HOLE <br /> TY FROM SURFACE TYPE <br /> DIA' Y w o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BE <br /> (inches) g ¢ zi a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m h coo LL (Inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (2!L) <br /> (TYPEISIZE) <br /> i <br /> i <br /> ATTACHMENTS 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 <br /> yT Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> SoiVWater Chemical Analyses <br /> Other I . l- ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-51 LICENSE NUMBER <br /> DWR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />