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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT 11111111111 <br /> PagRefer to Instruction Paugrhlet STATE WELL NO./STATION NO. <br /> • _ <br /> Owner's <br /> of Well No. No. W <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agency +.; ; <br /> APN/TRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING Mailing Address <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE DESCRIPTION <br /> Ft. to FL Describe material, grain size, color, etc. CITY STATE ZIP <br /> WELL LOCATION <br /> Address <br /> City <br /> County <br /> APN Boo Page Parcel <br /> Township Range Section <br /> Lat I t N Long W <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH <br /> _r NEW WELL <br /> I <br /> MODIFICATION/REPAIR <br /> Deepen <br /> l4 _ Other(Specify) <br /> i ( _ <br /> t <br /> _ DESTROY(Describe <br /> Procedures and Materials <br /> 1 <br /> Under"GEOLOGIC LOG') <br /> USES(2! ) <br /> I 1 - WATER SUPPLY <br /> pf _ Domestic _ Public <br /> ,l. —— Irrigation _ Industrial <br /> ul ~ <br /> Lu a MONITORING <br /> 3 1%' w <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION_ <br /> Illustrate or Describe Distance of Well from Roads,Buildings <br /> Fences,Rivers,etc.and attach ama . Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL Fc YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER _(Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I <br /> ESTIMATED YIELD' (GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORING l e I TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL _(Feet) *May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE( FROM SURFACE TYPE <br /> HOLE <br /> DIA. Y z x a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BE <br /> (Inches) w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m L) o�Q (Inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (�) (TYPE/SIZE) <br /> LL <br /> I y I <br /> I <br /> I 1 <br /> I 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 /> — Well Construction Diagram NAME <br /> (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil7Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />