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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page Of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> owner'sWell No. MW-13 _ _ No. 0931109 1 1 1 T <br /> E <br /> Date Work Began -10-.0LATITUDE LQNGITUD <br /> �tJ , Ended '�Z T <br /> •Local Permit Aaeney 5 ay%_ 4q,"",'1 I L Evil ;`-;,1 ►i:vr.� wir lk-oy) Ddr��. APNITRSIOTHER <br /> Permit No—ow-Lo Permit Date_-15'_D <br /> GEOLOGIC LOG F'" SELL OWNER <br /> tli{ � `1.� <br /> ORIENTATION _{SPECIFY} Named 4 5� ' 1+5< iu:lf5�{ktY, <br /> (_) ,iER71CA4 —HORIZONTAL —ANGLE <br /> DEPTH FROM DRILLING ��1 ,]' � UUJ41 FLUID } <br /> DRILLING <br /> 4 r ,;: Mailiiz Address �2�. r <br /> SURFACE DESCRIPTION ;',<. s iti�W O ',.,�. �U�] <br /> e ..-CITY -... STATE ZIP <br /> Ft. to FI. Describe material, grain size, color, etc"1, �� ! <br /> Wl LJ <br /> W <br /> 104 ittC�TIQ <br /> -� �. 10 r .� � � �•f �sr � <br /> Vl } ; <br /> �APN Book age Parcel <br /> r% te`` �- t N\ s• Towristiip!" Range Section <br /> �~ t., N Long I _L W <br /> DEG. MIN. SEC. DEG. MIN. Si <br /> LOCATION SKETCH A�IIVITY (�) <br /> NORTH <br /> NEW WELL <br /> I IL; i MODIFICATIONIREPAIR <br /> Deepen <br /> — Other(Si <br /> _ DESTROY(Describe <br /> pro <br /> Cadures and Materials <br /> Under"GEOLOGIC LOG") <br /> USES('') <br /> WATER SUPPLY <br /> \J _ Domestic _ Public <br /> � Irrigation IndustrialCn <br /> - <br /> I I tL d�d MONITQRING <br /> W <br /> TEST WELL <br /> I i CATHODIC PROTECTION <br /> I I <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> I f <br /> INJECTPON <br /> VAPOR EXTRACTION <br /> SPARGING— <br /> i SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Suildings <br /> Fence,Rivers,etc.and attach a map.Use additional paper if OTHER(SPECIFY)_ <br /> necessanJ.PLEASE BE ACCURATE&COMPLETE. <br /> I � <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> .I i DEPTH TO FIRST WATER 50 (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> I I WATER LEVEL (Ft.)&DATE MEASURED <br /> I I <br /> ESTIMATED YIELD ' (GPM) & TEST TYPE <br /> TOTAL DEP'T'H OF BORING �5 (Feet) TEST LENGTH (Hrs.J TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) `May not be representative of a Welly long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE('') FROM SURFACE TYPE <br /> DIA- x Q a MATERIAL INTERNAL GAUGE: SLOT SIZE C:�T <br /> [TC <br /> EN- <br /> (inches) a zU a GRADE DIAMETER OR WALL IF ANY MNITE FILL FILTER PACK <br /> Ft. to Ft, m oQ (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEJSIZE) <br /> LL �) rte) <br /> V S <br />— I 1 <br /> I <br /> I <br /> ITTACHMENTS (2�L) CERTIFICATION STATEMENT <br /> I,the Isndem ned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Z Geologic Log pry <br /> well Construction Diagram NAME I� �^Y(��rEr��J _ <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) •'�� <br /> _ <br /> Geophysical Log(s) ����,�� I <br /> OoIllWater ;M Analyses -��.Rrh2�► .1k &.. .w SSL) I4711'Y1�(rSirl fad( _ CA �S <br /> ther SADDRESS 1 CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Sf9ned � "A�ONTRACTOR <br /> I� r f 6 4 w5 b„�C-57 LICENDATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV. 03-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 76836 <br />