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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 <br /> Pa Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well No. <br /> g �'1L-2 No. <br /> 0931106 <br /> Date Work Began `�'�' , Ended '� "061 LATITUDE LONGITUDE <br /> ff 11`' <br /> Local Permit A e Sin\ "Pas-1.31A LV-14 4ie�slvYL liC ll�1 art <br /> -1 '�- APNlTRSlOTHER <br /> Permit No. ���ZI -Permit Date 3'15::Db <br /> GEOLOGIC LOG [7���j ` �VELiy�Lc OWNER <br /> ORIENTATION (✓) _VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) NameA+`i1�li , _�� !T '44 M1 S <br /> DRILLING ')S` \ s <br /> METHOD FLUID ;Ivl i ing Add <br /> DSURFAEPTH CEM DESCRIPTION ' -�, _> 04 <br /> Ft. to Ft. I�BSCr'Yl7e material, gT(tl7Z size, co or, etc.`,`,, �.`i c€NTrv,� ,,,� i '1 �S ! STATE ZIP <br /> ^..Address. _`` 2 W\1\ F ++ W L LO ATI 14. ' t 1� <br /> I I <br /> ' ' � SSif lc�:i� �'� C r '+' `t, '.GiSI t �C rytJ��t� �'�' '�-•`'j Lf <br /> Ouniy <br /> ``APN Book �' Page Parcel <br /> tf i tt`l j 1 "� "� ✓'A s �� <br /> Towiishig` Range Section <br /> Long g i w <br /> t �. <br /> V DEG, MIN, SEC. DEG. MIN, SEC. <br /> LOCATION SKETCH ACTIVITY (.�L) <br /> „-: NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> See `'rI> 1 — Deepen <br /> r _other(Specify) <br /> ' - DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG”) <br /> USES i <br /> I �1� ��: 0• �`I' WATER SUPPLY <br /> _ Domestic _ Public <br /> ' ' h Irrigafon _ Industrial <br /> cn <br /> Lu <br /> 1¢ MONITORING <br /> ' I TEST WELL <br /> I I CATHODIC PROTECTION <br /> I I HEAT EXCHANGE <br /> i DIRECT PUSH _ <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I <br /> SPARGING �.. <br /> I I SOUTH <br /> Illustrate or Describe Distance of Well from Roads,Buildings REMEDIATION <br /> I I Fences,Ricers,etc.and attach a nwp Se additional paper-Y OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> I i <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I , ' <br /> 1 DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> I DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> t e <br /> ESTIMATED YIELD ' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH <br /> (His.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of s well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE i FROM SURFACE -TYPE <br /> DIA, x a a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE_ BEN- <br /> (Inchss) ¢ z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m 0 M � (Inches) THICKNESS (Inches) Ft. to Ft. (TYPEISIZE) <br /> I I <br /> I I <br /> I I <br /> I I <br /> ATTACHMENTS (.�L) CERTIFICATION STATEMENT <br /> Geologic Lo r <br /> I, the undersl ned,certify that this re Orl is complete and accurate to the best of my knowledge and belief. <br /> Well Construgction Diagram NAME � _— �)Jy Gl i�2 /j y l <br /> (PERSON, FIRM, OR C RPO ATION) (TYPED[1R PRINTED) <br /> Geophysical Logs) ?, <br /> OoiUWaterCthe�tmical Analyses / � �+ <br /> ther i l�l1�. ADDRESS /./[]] Ire,, jf' �.J} ��^! CITY �)J/j STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, 1F IT EXISTS. Signed SLN`✓�" ]t r !� ���4rl�'y ` J� " �V� <br /> C-57 LICENSED WATER CO TRACTO J E SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV, 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM DSP 03 78836 <br />