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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 '� Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well No. t9t��" No. 0931108 <br /> Date Work Began -0uEnded -oc, LATITUDE LONGITUDE <br /> • Local Permit Agency �-M or, 'ii v" EAvj r4 r ��(L160 <br /> 7T. <br /> Permit No., R <br /> �{ 'j j I� _ Permit Date J Z� <br /> GEOLOGIC LOG \WELL OWNER <br /> _-) <br /> ( <br /> ORIENTATION y ► yo (1 J �`�' y� p .✓1 <br /> VERTICAL 3 _HORIZONTAL —ANGLE —(SPECIFY) Name; '+'��� V � <br /> DRILLING '{�- eI c'�� Q% � ) v �L,V <br /> DEPTH FROM METHOD FLUID M' Ing'AddreS§ <br /> J! ✓ q S . <br /> SURFACE DESCRI TION `;\.'\� �I1 '' - ` t ./" CA 11 <br /> Ft. to Ft. Describe material, grain size, Color, eta.`­'-, \�� 'CI;) .-\ STATE ZIP <br /> WE L WCATION <br /> /� p.,Address �'� "C ` ^ & ,rVwJ <br /> ' I "4' � ''d r- f'•.,1 \. i L f w' 1 �Ult `* _ Y.. I`✓uj-S 5% <br /> �APN Book Page Parcel <br /> ' ' ��� � i ./• n <br /> Towii�E�ip'°: • Range Section <br /> Lat N Long I w <br /> ' � 1,> �.✓� � rug 5�'' DEG. MIN. SEC. DEG- MIN. SEC. <br /> LOCATIOv SKETCH IVITY (�) <br /> i } } _ <. .-S NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> ' ' r✓ \ \ l _ Deepen <br /> Other(Specify) <br /> <l1i.t. <br /> t DESTROY(Describe <br /> 77 - Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> ♦5 USES (2L) <br /> WATER SUPPLY <br /> I I " — Domestic _ Public <br /> I_ _ Irrigation _ Industrial <br /> In <br /> W W MONITORING <br /> I I � <br /> TEST WELL <br /> ' I CATHODIC PROTECTION <br /> I HEAT EXCHANGE <br /> I DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> I I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of WeII from Roads,Buildings, <br /> I i fences,Rivers,etc.and attach a map, Use additional paper if OTHER(SPECIFY) <br /> necessany PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> WATER LEVEL_ & YIELD OF COMPLETED WELL <br /> i DEPTH TO FIRST WATER 30 (Ft,l BELOW SURFACE <br /> DEPTH <br /> WATER OLE STATIC 5� <br /> J (Ft.)&DATE MEASURED <br /> I I <br /> # ESTIMATED YIELD ' (GPM) & TEST TYPE <br /> TOTAL. DEPTH OF BORING f #S (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL. DEPTH OF COMPLETED WELL *May not be representative of a well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPED FROM SURFACE TYPE <br /> DIA. 77 Y:gj w p a MATERIAL! INTERNAL GAUGE SLOT SIZE CE- SEN- <br /> (inches) LU o� (,RADE DIAMETER OR WALL iF ANY FILTER PACK <br /> Ft, to Ft. v v = <br /> (inches) THICKNESS MENT TONITE FILL ( } <br /> Y (Inches) Ft. to Ft. TYPEISIZE <br /> 0 ' 0 V <br /> LL N&51A,4t0 Z G 1D <br /> 0s 115 S V I I ft 5. Z_ <br /> 03 ' 115 Z <br /> ' 56L <br /> I <br /> I <br /> TACHMENTS (:) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME 1.r L i1 1i /ptj fl I s}V} <br /> Geophysical Log(s) <br /> (PERSON, FIRM, OR CORPORATION) (TYPEDAM PRINTED) <br /> G9 Y J <br /> JSolU4n+aier Chemical Analyses I' r t? ;'Il; 1 5S $Z <br /> —2/other rQ ADDRESSII CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed�� &d <br /> ' /t f 1lj kT <br /> SED WATER W L CONTRACTOR EIS NED C-57 LICENSE NUMBER <br /> DWR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />