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STATE OF CALIFORNIA n EPOR�, ATtON N9_• <br />ORIGINAL COMPLETION i, STATE WE��'gT <br />File with DWR WELL <br />Nrfrr to In.Hnrrlpni Pnmphlrr LONGITUDE <br />Page _ of _ No. LATITUDE I I I 1 I <br />Owner's Well No. p I` <br />ate Work Began { 210� 1 , Ended ' I ( I APN/TRSIOTHER <br />Local Pennit Agency <br />Permit No. Pennit Date WELL OW ER <br />GEOLOGIC LOG [ ��1 ^I I \ S <br />{{ ZONTAL _ANGLE (SPECIFY) Nante <br />ORIENTATION (�) 1 VERTICAL HORI <br />.�Wp_LING v �at06 FLUID Mailing Address ZIP <br />'�9ETHOD M STATE <br />DEPTH FROM BES BIPTION CITY <br />SURFACE WELL LOCATION <br />Ft. Ic L Deterlbe material, Kram color, etc. <br />C avLv � Address <br />a� Citr' <br />Si County <br />yta I �J APN Book Page Parcel <br />19 C aL Township Range Section wesT <br />( _ NORTH Longitude <br />Latitude <br />2 'C. , DEG. MIN. SEC. PEG. MIN. SEC. <br />Ra LOCATION SKETCH ACTIVITY (=) <br />' NORTH )4L NEW WELL <br />e I -N h v' <br />MODIFICA 71ON/REPAIR <br />'ti 5 tOO t7Yw•Q/ <br />—Deepen <br />Other (Spealy) r <br />DESTROY (Dracribe <br />Procedures entl Malone[$ <br />c7 Under 'VEOLOGIC LOG-) <br />�Z PLANNED USES (_) <br />WATER SUPPLY <br />oameenc Public <br />I ` 1 Irdgalion IndueUiei <br />F- <br />II gi MONITORING _ <br />U) 3 TEST WELL <br />7 I CATHODIC PROTECTION <br />=17 I HEAT EXCHANGE <br />(D - DIRECT PUSH <br />- _ INJECTION <br />VAPOR EXTRACTION <br />r ate• �"B SPARGMG _ <br />'S H <br />rin ftrrorh, REMEQIATIONIffat i'vor DenbDTrtaun•rf1Y•fln <br />TBnflrirKs, <br />c . .1 <br />_ w)x'r if OTHER tSPECIFY) uectuonJ. PLEASE BE ACCURATE & CObfPLET18 <br />I <br />WATER LEVEL do YIELD OF COMPLETED WELL <br />' I DEPTH TO FIRST WATER 150iS(Ft.) BELOW SURFACE <br />' DEPTH OF STATIC <br />WATER LEVEL ��� (Fl,) d DATE MEASURED <br />TOTAL DEPTH OF B0R11"G ESTIMATED YIELD • e+'� (GPM) g TEST TYP <br />— �—(Feet) TEST LENGTH <br />TOTAL DEPTH OF COMPLETED WELL 6D Feet) (We. <br />ive TOTAL pRAwDOWIL— (FI ) <br />hiay not Gr rx rrsenmtrve o a mell'S lore -teen yield. <br />I <br />DEPTH , BORE CASING (S) <br />FROM SURFACE HOLE TYPE DEPTH ANNULAR MATERIAL <br />DIA. MATERIAL! INTERNAL GAUGE FROM SURFACE TYPE <br />FI. to Ft. •(Isches) C, 'GRADE DIAMETER OR WALL SLOT SIZE <br />S4i 0 ilmhes) THICKNESS (I ANY CE- DEN. 2 x <br />n011°') Fl. to Ft. MENT TONFTE FILL FILTER PACK <br />2" b <br />7TS o (TYPE/SIZE) <br />1-0 15� x c T6 <br />No .o3s lex i� <br />(0 r ImC x G YGI-A <br />ATTACHMENTS (�) <br />t <br />— Geologic Log I, the unoerel n CERTIFICATION- STATEMENT <br />undersigned, Dartlfy that this report is Complete and accUr$teto (!ta best Of my knpyygd9e and belief. <br />_ Wel! Consinnyipn D)agr� <br />NAME <br />Geophysical Log(g) (PER 2i, RRM, OR fd7RPORATI - <br />- SoiWuater Chemical AnaNeesI1rPE0 PRINTEDt <br />, <br />— Other ADORESS <br />ATTACH ADD/TIONAL'INFORMA TION, IF IT EXISTS. <br />8Vled <br />DN'li IM; HEN „L. WELL IUERIAUTHt1RIZED REPRFSEMATIYE SWE 2tP <br />NEEDED <br />IF ADDITIONAL SPACE IS NE <br />cQ , USE NEXT <br />O CONSECUTIVELY �7UM UCEI` E� _ <br />..._� _ <br />0 <br />-0U) <br />OfD <br />O Q <br />Q. <br />rn <br />Z <br />Cn � <br />n o <br />O� <br />Z <br />CL <br />�0 <br />(D <br />O <br />O <br />o. <br />