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ORIGINAL STATE OF CALIFORNIADWR USE ONLY — DO NOT PILL IN <br /> File with DWR ,LL COMPLETION REPORT <br /> Pae f of,l_ Refer to InTtruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No <br /> Page mw-lb No 0912966 <br /> Date Work Began_ 0-0 LATITUDE LONGITUDE <br /> �" _ — Ended � "� <br /> Local Permit A ency �.>7 .�''l�f�-i� U t'L'cl pfo- 2 _. <br /> _._._ <br /> Permit No 6 Permit Date 3"q �f APNITR5/OTHER <br /> GEOLOGIC LOG r` {fir,_ WE L OWNER <br /> ORIENTATION (�) VERTICAL —HORIZONTAL _ANGLE —(SPECIFY) NalnDRILLING <br /> e ``yy,'r �1$ • a �• <br /> DEPTH FROM METHOD A('k-Y ) +.�� FLUID ,Mail��Addle5S�2i��L.�� <br /> SURFACE DESCRIPTION `�\�'� it 1}" \\ / �'' <br /> Describe materaal groan sate color etc`\ �u DI �,r } STATE zl <br /> Ft to PI LOCA IgiV <br /> ,,\ ; \.^ .tlddress ' .� t '" 'z ' Fn^�✓ytr rr � " <br /> i I 1�l ' <br /> L Gotanty-� 6r.t ry <br /> 4r' s /�"� �� - APN Book Page Parcel (jam <br /> Township f Mange Long <br /> N Lon I I W <br /> I • �''� �✓f f ^}J�'' DEG MIN SEC DEG MIN SEC <br /> r LOCATION SKETCH A ITY (�} <br /> NORTH <br /> S— NEW WELL <br /> MODIFICATIONIREPAIR <br /> _ Deepen <br /> I I 1 / ''✓ ��, 1 t �'"Y✓1 — Other(Specify) <br /> t f rr� i <br /> DESTROY(Describe <br /> Pro duras and <br /> Underi GEOLOGICtLOGsJ <br /> USES () <br /> WATER SUPPLY <br /> I I - Domestic Public <br /> Irrlgatlan Industrial � <br /> n <br /> '"'t u) <br /> MONITORING <br /> Lu <br /> TEST WELL <br /> I s CATHOMC PROTECTION <br /> I I HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I <br /> SPARGING _ <br /> SOUTH <br /> I I REMEDIATION <br /> IIltistrate or Describe Distance of We I2 from Roads Buildings <br /> Fences Rivers etc and attach a Wp Use additional paper if OTHER(SPECIFY) _ <br /> necessanj PLEASE RE ACCURATE&COMPLETE <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> I I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED 3�_3�5 <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) 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 TYPE(—') FROM SURFACE TYPE <br /> DIA x w o¢ a MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) S ¢ zU J GRARE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m o LL (Inches) THICKNESS (Inches( Ft to Ft (� {�) ('`) MPE/S€ZE) <br /> V 36 Z �Y <br /> I I <br /> I <br /> I I <br /> ATTACHMENTS (�:L) CERTIFICATION STATEMENT <br /> glc Log <br /> I the underst ned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> G� i_+ <br /> V Well Construction Diagram NAME 4� -5 Fw,l,�;J C, <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Logi(s) 7 e� !, r / f! 1 P,7)( <br /> r <br /> Other at 1 eml Analyses 3s✓ (4f 14 ll - _ 5(j `/.r4f II1)( L/T <br /> ADDRESS CITYL.� `� STATE�y ZIP <br /> ATTACH ADO1TlONAL 1NFORAhATlON 1F!T 1 XISTS Signed L�� � ri "'vf 0 /I 1'1 I iJ f— * /' } <br /> C 57 LICENSED WATER�SIEL CONTRACTOR DATE SIGNED C 57 t€CENSE NUMBER <br /> DIVR 188 REV O5 03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />