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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> ,File with DW RLL COMPLETION REPORT <br /> Page Of I Refer to lnstractton Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No NO 0912964 <br /> LATITUDE LONGITUDE <br /> Date Work Began —1�:P' Ended 3'SO"6q <br /> LOCal Permit Agency ��� �I� 6 _40 <br /> Permit NO 311� ermlt Date 3 -z APNrFRSIOTHER <br /> GEOLOGIC LOG r \WELL OWNER <br /> ORIENTATION (✓) —VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Name <br /> i <br /> DEPTH FROM <br /> METHOD FLUID ,'' `MG11111 Cdr Lo/ �` ��� , <br /> SURFACE DESCRIPTION ��� `} 1\ <br /> Ft 10 Ft Describe material grain size color etc� ��` Ct I STATE ZIP <br /> �'^ � � � �� W LL LOCATION <br /> '�r��r�►t�' <br /> i <br /> WeQ W,A 09 ' 5,14, <br /> /I�Cwr ` �} �5,y,/�-L 'an {��f <br /> ^ Vy 4,-o.(.t PN Book t Page 150 Parcel 03 _ <br /> ,. <br /> u,'`, 1r Jl `� T`otivnsh p�"- Range Section <br /> NW <br /> I -- w <br /> i I l / / '� y \s✓ / - i r ti DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> A t\k;� C,61\ _I v \! NORTH <br /> — NEW WELL <br /> MODIRCATIONlREPAIR <br /> — Deepen <br /> i I i iJ <br /> . — Other(Specify) <br /> ' DESTROY(Describe <br /> Proceures and us <br /> ' Sy`'' �f '�,•-✓ '� �,�' enals <br /> Under GEOLOGICILOG) <br /> USES (2!L) <br /> WATER SUPPLY <br /> _ Domestic — Public <br /> I <br /> Irrigation Industrial <br /> Lli <br /> l4 MONITORING <br /> I I TEST WELL <br /> I I <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> ! I DIRECT PUSH <br /> ! ! INJECTION <br /> ' VAPOR EXTRACTION <br /> t I SPARGING <br /> SOUTH REMEDIATION _ <br /> Illustrate or Describe Distance of Well from!toads Buildings <br /> Fences Ravers etc and attach a map Vse addtttosal paper of OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> `NATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> ! I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i DEPTH OF STATIC <br /> WATER LEVEL (F1)&DATE MEASURED <br /> i ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WILL (Feet) *May not be representative of a well's long-term yield <br /> DEPTH SORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(' ) FROM SURFACE TYPE <br /> DIA Y w p a MATERIAL 1 INTERNAL GAUGE SLOT SIZE: CE BEN <br /> (Inches) a o0 a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> F1 to Ft m U c�7 (Inches) THICKNESS (inches) Ft to Ft (TYPEISIZE) <br /> I <br /> I I <br /> I I <br /> I I <br /> I I <br /> ATTACHMENTS 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 /> — ( <br /> Well Construction Diagram NAME ✓4� a SAt, <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) �t <br /> Geophysical Log(s) 6,.4 <br /> ogs) f k �` S., Sok [� ry <br /> Sod/Water Chemical Analyses �" �Z r� ■ <br /> ADDRESS f/ r J��] I� / CITY �7r <br /> x Other Sa�?� lLl 1^" l,r''� Yi _ STATE-71607/ <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed �c, Y .1_fi l <br /> C 57 LICENSED WATER'�W LL CONTRACTOR Tl DATE SIGNED C 51 LICENSE NUMBER <br /> DWR 18a REV 0-03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM � OSP 03 78836 <br />