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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR J *LL COMPLETION REPORT <br /> Page A of i Refer to Instruction Pamphlet STATE WELL NOISTATION NO <br /> ONVner'S Well Noi y I NO 0912967 <br /> . Date Work Began3Oq Ended LATITUDE LONGITUDE <br /> Local Permit A ency � -1 & ;A, r P}45-rFij) <br /> 7 APNITRS/OTHER <br /> Permit No ��t 't Permit Date `� <br /> GEOLOGIC LOG ;t r ELL OWNER <br /> r <br /> ORIENTATION (2�L) VERTICAL HORIZONTAL ANGLE (SPECIFY) Name <br /> DRILLING j. f1 ++,, 1 ✓^ �/ <br /> DEPTH FROM METHDD �`�� `• - tfbyl�L"i.li(39 FLUID 'Mailing Address1 � la { �r,v't! <br /> SURFACE DESCRIPTION ti��ti `` te7 <br /> Ft to Ft Describe material grain size color etc <br /> STATE ZIP <br /> WELL LQ CATION <br /> I I 5' 1r YiZ' � l t�! (�_\���J f //'� D� �G.j{�!�� �� .i io 1��+✓' <br /> APN Book15,)Page IParcel V- <br /> -� <br /> < a' Township r, Range Section <br /> Lang I I W <br /> DEG MIN SEC DEG MEN SEC <br /> LOCATION SKETCH AC •INITY { ) <br /> NORTH _ NEW WELL <br /> MODIFICA710NIREPAIR <br /> _ Other{SPecItY) <br /> DESTROY(Describe <br /> Procedures and Materla's <br /> Under GEOLOGIC LOG} <br /> USES (✓) <br /> WATER SUPPLY <br /> Domestic _ Puhkl6 <br /> Ifrlgaticn _ Industrial <br /> � H r <br /> rn <br /> Iw q MONITORING a� <br /> I TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> I I VAPOR EXTRACTION <br /> I I SPAAGING . . <br /> SOUTH REMEDIATION <br /> Illustrate or Descnbe Distance of Well from Roads Builds. <br /> Fences Raters etc and attach a map Use additional paper:f OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> I I <br /> WATER LEVYL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATICfp ^7,D <br /> WATER LEVEL rs (Fl)&DATE MEASURED ,] <br /> ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (rt) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE(''—') FROM SURFACE TYPE <br /> DIA Y ¢o a MATERIAL I INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) ¢ a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> TYPESIZE Ft to <br /> Ft to Ft m v o� � (Inches) THICKNESS (Inches) Ft ( ) <br /> I ,.LW I <br /> bob I G 'Z- IT Z �v <br /> 0-L �+ <br /> I <br /> I I <br /> I I <br /> 'TTACHMENTS (2�.) CERTIFICATION STATEMENT <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief <br /> oologic Log lL Uf 1 <br /> ell Construction Diagram NAME 5 5 , '1}'+(A i,'`) VIM4 6y+, j' V <br /> Geophysical Log(s) (PER{SSOOONN3 FIRM OR CORPORATION) (TYPED OR PRINTTEED) (/� r7 d <br /> oiVWater Chemical Analyses 1 -`1 RVA A �Ll J � '`- prw r 2 L.�� f K � <br /> q ADDRESS �] CITYiSTATE �pZIIPP��r11t r ;e `l �� 7/dJ4f� ! 3'ATTACH ADPlT10NAL fNFORMA7tON 1F 17 EXISTS Signed Igg <br /> Ir+f7"`LED WATER WELL CDNTRACTOR DATE SIGNED C 57 LICENSE NI.JMBER <br /> DWR 188 REV 0503 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM = OSP 03 78836 <br />