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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> Fife with DWR *LL COMPLETION REPORTI�107 I I t <br /> Page__L of J_ Refer to In /STATION NO <br /> Pamphlet STATE WELL NO/STATIONO <br /> _ <br /> Owner's Well No Mw-15 NO 0912965 <br /> . Date Work Began 35`Z Ended 30:q LATITUDE LONGITUDE <br /> Local Permit A ency a' — 4.' ri <br /> I 5. APNrrRSIOTHER <br /> Permit No _ _ 6 Permit Date� � <br /> GEOLOGIC LOG tet` WrE.,L�L OWNER <br /> : <br /> ORIENTATION ( ) =VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) NaiXie �5 i�� tli� .�G�[.-iIPA <br /> DRILLING f *f� \r Z �Jl��C1Y�' <br /> DEPTH FROM METHOD k1(i.0 a 1Ata j& FLUID ,Mailing,Address r A — <br /> SURFAOE DESCRIPTION T t`, `" 4ILl�y"YItI _�. �,�`t' 'N50 <br /> Ft to Ft Describe material grain size COIOr ets' \� Ci t ..n \ \ \ 4 STATE ZIP <br /> V : 1 \ S (ELL LpCAION <br /> ..Add k'�'2yrrG <br /> ounty-_5u.1 16214\Lk <br /> �APN Book ' Page I ic; Parcel 4 <br /> } �� ! ✓ Townsbtipr Range Section <br /> Lit N Long I W <br /> DEG MIN SECDEG MIN SEC <br /> F } a' _ LOCATION SKETCH AVIVITY (�) <br /> Ji <br /> NORTH _L�'NEW WELL <br /> MOOI F ICATDeepe1PAIR <br /> IR <br /> Deepen <br /> I I /i <br /> — Other(Specify) <br /> DESTROY(Descnbe <br /> Procedures and Maienals <br /> Under GEOLOGIC LOG} <br /> � USES {�) <br /> WATER SUPPLY <br /> Domestic -� Public <br /> F- � IrngaLon Industrialco � <br /> w / <br /> I � � MONITORING.7/ <br /> TEST WELL <br /> I 1 CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> i I DIRECT PUSH <br /> INJEC71ON <br /> I I VAPOR EXTRACTION <br /> I I SPARGING _ <br /> I I SOUTH REMEDIATION _ <br /> Illustrate or Describe Distance of Well from Reads Buildings <br /> Fences Rmers etc and attach a map Use addrtmnalpaper f OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> I I DEPTH TO FIRST WATER 4545—(Ft) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (FI)&DATE MEASURED3-2_ <br /> I I ESTIM -05 <br /> ATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL __ _..__(Feet) *iWay not be representatrue of a Well'$long-term yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE O=) FROM SURFACE TYPE <br /> f?IA Y w a MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) ¢ Z r- a GRADE DIAMETER OR WALL IF ANY MENT TONJTE FILL FIi_TER PACK <br /> FL to Ft m C cg �_ (Inches) THICKNESS (Inches) F1 to Ft (TYPEISIZE) <br /> `n li (2' ) (Z!) (2L) <br /> �L Z <br /> I <br /> ATTACHMENTS (.!L) CERTIFICATION STATEMENT <br /> I,the undersf ed certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Geologic Log5 �' f � <br /> K Well Construction Diagram NAME 'f _S �=4 ty*L✓y lh ' Tf it <br /> Ge0physical Log(s) (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> 3� Yl> S5 <br /> ilcal Analyses IL7SoiWater Chel � L <br /> Other fir yH". ADDRESS ; CITY STATE ZIP <br /> `] _ '7 <br /> ATTACH ADDlTfONAL INFORMATION 1F 1T EXISTS Signed y�' fr' <br /> C ST LICENSED WATER WELL CONTRACTOR DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 05 03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM �& OSP 03 78836 <br />