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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FIL. IN <br /> File with DWR WELL COMPLETION REPORT <br /> STATE WELL MO./STATION NO. <br /> Page�Of Refer to Instruction Pamphlet <br /> Owner's Well No. 11 '" y� No. <br /> 0931107 <br /> Date Work Began � ��'U L � 'Z—�� LATITUDE LONGITUDE <br /> Ended <br /> Local Permit Agency t i ;tom. vlj lu llf Tv III I -11- If <br /> • I 7 r AFNITRSIOTHER <br /> Permit 1�Ia._ 1"� } Permit Date 11,1'6 j� <br /> GEOLOGIC LOG \WELL OWN R <br /> ��? � � " <br /> ORIENTATION (✓) —VERTICAL _HORIZONTAL _ANGLE —(SPECIFY) Nam 'tJt, ? 5.5c I z�>1 114 <br /> DRILLING `- ?)' y 'E N ' <br /> DEPTH FROM METHOD FLUID /' >Ma 1SIig Address f t <br /> p� i 'Itr <br /> SURFACE DESCRIPTION +,_1 ,y _ _ - � <br /> Ft. to FL Describe inaterial, gain size, color, etc.,, �,r•'-'CII`1C� 'S \•\5 1 0 STATE ZIP <br /> i i J; WEL ��yyOC TION ff <br /> y/1I r,y [tYt.S <br /> _ Add <br /> resVX <br /> e l� <br /> pff <br /> County r t _ <br /> APN Book r`' Page s Parcel <br /> Township ' r Range Section <br /> )[ .•.o' " .r \� .� t %Lot %':>` I N Long 1. w <br /> ❑EG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> 1 NORTH 1'r_•"? �r' ` NEW WELL <br /> �-^-�•� ,l J MODIFICATIONIREPAIR <br /> e� i ,c/f — Deepen <br /> _ Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> ' Under"GEOLOGIC LOG") <br /> USES U <br /> V P <br /> "� WATER SUPPLY <br /> �.' — Domestic _ Public <br /> F — Irrigation _ Industrial <br /> m <br /> Ld <br /> w MONITORING <br /> I <br /> TEST WELL�. <br /> I CA7HODIC 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 /> �F <br /> Fences,Ricers,etc.and attach a�rnsp Use additional paper i OTHER(SPECIFY) <br /> necessarrf.PLEASE BE ACCURATE&COMPLETE, <br /> I I <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 (Feet) <br /> TEST LENGTH (Hrs.}TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a weld's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPED FROM SURFACE TYPE <br /> DIA. Y w p a MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (inches) ¢ ¢ o� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. Ef N coo LL (Inches) THICKNESS (Inches) Ft. to FL (TYPFJSIZE) <br /> ( ) ( } (:) <br /> I , <br /> I <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the unders geed,certify that this re ort is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log n <br /> Well Construction Diagram NAMEh�1 ''I y r r <br /> _ Geophysical Log(s) iFERSON, FIRM,OR CORPQRATIOm) {TYPE OR PRINTED) l C Q 7 <br /> oilMlater hemical Analyses •+330 *3 4=U� t, ` ;,;i <br /> ADDRESS CITY �E ZIP <br /> _V yTOther j/, 1 ►ir 1 %57LANSELNUMLEff—R —j <br /> Signed slrlr!" L'J.f�i C (! I le1,L I !+ b" �'}ATTACH ADDf710NAL lNFOAMATION, 1F!T EXISTS. 7 LICENSED WA R WE CONTRACTOR DATE SIGNED <br /> DWR 188 RII G"3 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM Iffig DSP 03 78836 <br /> r <br />