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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT PILL IN <br /> File wih DW WELL COMPLETION REPORT <br /> Page—of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well NoAW-3 No. 0931105 <br /> Date Work Began Y+' ""w v,Ad 1 t_,Dlb LATITUDE LONGITUDE <br /> Local Permit A ency1�., N�,..-+ ct tr't A � yi/ ee?.l: <br /> Permit NO. R '"SVAPNiTRSroTHER <br /> Permit Date .; <br /> GEOLOGIC LOG r%" WEL OWNER <br /> ORIENTATION c � ���� '4 <br /> � � ✓�J <br /> {—�J VERTICAL _HORIZONTAL _ANGLE (SPECIFY) Name - ' 4Y <br /> DRILLING i y— h <br /> DEPTH FROM METHOD FLUID �_';Nla� 'ilg Address <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. �BSCri17e»TQtE?'tQI, grains size, color, efc.�:� ""C��. STATE ZIP <br /> TLON <br /> Address _, <br /> kk Li <br /> Fi ; •^. ;r� , <br /> .� !� <br /> �COunty' 5 L_H �il✓N <br /> PN Book Page Parcel <br /> TON ii h p; Range <br /> ' 1 .Clr�'" T J l•' ;, Section <br /> Long w <br /> DEG. MIN, SEC. DEG. ' MIN. SEC. <br /> "i �w.� t✓�,r v i;\r LOCATION SKETCH ACTIVITY (2L) <br /> NORTH NEW WELL <br /> MODIFICATIONIREPAIR <br /> — Deepen <br /> I I �+ �� _ Other(Specify) <br /> DESTROY(Describe <br /> [ .+'S \..✓ 'v {•!;-�� Procedures and Materials <br /> p y Under"GEOLOGIC LOG") <br /> USES{�) <br /> WATER SUPPLY <br /> i i �'' — Domestic _ Public <br /> — Irrigation _ Industrial <br /> LU <br /> MONITORING <br /> TEST WELL_ <br /> ' CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRE=CT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> I i SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> Fences,Rivers,etc.and attach a Use addition¢t ppaper if OTHER(SPECIFY) <br /> necessanj.PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> E DEPTH TO FIRST WATER (Fl.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (F;,)&DATE MEASURED <br /> TOTAL DEPTH OF BORING EST"MATED YIELD (GPM) 8 TEST TYPE <br /> (Feet) 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 /> DEPTHBORE_ CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE ii FROM SURFACE TYPE <br /> DIA. z �o a MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) g ¢ `o, a GRADE DIAMETER OR WALL IF ANY <br /> MENT TONITE FILE. FILTER PACK <br /> FI. to Ft- m N OQ <br /> (Inches) THICKNESS (inches) Ft. to Ft. (TYPEISIZE) <br /> ATTACHMENTS I CERTIFICATION STATE,VIENT <br /> Geologic Log <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> n <br /> Well Construction Diagram NAME W3 AviiiY,V)� <br /> Geophysical Logs) -3336 <br /> (PERSON, FIRM, OR CORPORATION) ((YPED PRINTED) <br /> SoiliWater Chemical,Analyses 3rayAwyL{t DP SIVU-556 r <br /> . 6 CM Z <br /> Other ADDRESSCITY ( f STATE ZIP <br /> ATTACH ADDfTIONAL INFOR TION, IF 1T EXISTS. Signed hr <br /> C-57 LICENSED WATE WELL CONTRACTOR DATE SIGNED C-57 LICENSE Ni <br /> nwR 188 IiEV 05.03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />