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ORIGINAL STATE OF CAI IFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File wit DWR ELL COMPLETION REPORT <br /> Page ofi— Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> wn <br /> Oer's Well No j N° 0 912 9 6 S <br /> Date Work Began�31-W Ended 3—31 LATITUDE LONGIruoE <br /> Local Permit Agency ~0st ° t. 61044 - .,� <br /> Permit No C ;2 Permit Date - APNlTRSlOTHER <br /> GEOLOGIC LOGr WELL OWNER <br /> ORIENTATION r � � <br /> (,) L VERTICAL _HORIZONTAL —ANGLE —(SPECIFY) Namesal <br /> DEPTH FROM METHOD � 1,>1�1 +'t Ls A FLUID r M ling Address 2 Z� Y �IJ'1 !`ve <br /> SURFACE DESCRIPTION \ �"� <br /> Ft t0 Ft Describe material grain size color' etc \ ClSTATE ZIP <br /> Add\Ss T.2 W L LOC TI� <br /> 40, <br /> APN k_l5 age . 1270 Parcel 03 <br /> Township 6 Range Section <br /> I ,I N Long I i w <br /> I f�'� \� �� �✓�/ „,����� DEG MIN SEC DEG MIN SEC <br /> s-:�y`` ✓� ✓ 4 \ �r LOCATN N SKETCH AC,�IVITY (�) <br /> t_/N EW W E L L <br /> ' /f `'a.�� 'Yy �• �=:� \�y��,,,J/ c' � �leL{/� MODIFICATION/REPAIRDeepen <br /> d J P <br /> _ Other(Speclly) <br /> DESTROY(Describe <br /> ' ` ' /"i `•.—.�`" \t \ Procedures and Ill <br /> Under GEOLOGIC LOG J <br /> USES l <br /> ' WATER SUPPLY <br /> Domestic — Public <br /> 1 I y Irrigation _ Industrial <br /> i <br /> 3 w MONITORINGt- <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> I I <br /> HEAT EXCHANGE _ <br /> I DIRECT PUSH _ <br /> I , INJECTION <br /> I 1 <br /> VAPOR EXTRACTION <br /> SPARGING <br /> I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads Bunkhngs <br /> Fences litters etc and attach a msp Use addittonal gaper III OTHER(SPECIFY) <br /> necessary PLEASE BE ACC[IRATE&COMPLETE <br /> WATER LE'VFL & YIELD OF COMPLETED WELL <br /> I I DEPTH TO FIRST WATER W(Ft} BELOW SURFACE <br /> DEPTH <br /> STA <br /> WATER OLE EL TIC (Ft)&DATE MEASURED 5-3-61:5 <br /> ESTIMATED YIELD {GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING q (Feet) TEST LENGTH (i TOTAL DRAWDOWN (Fl) <br /> TOTAL DEPTH OF COMPLETED WELL _50-{Feet) 'May not be representative of a well's long-term yield <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE OL) <br /> FROM SURFACE TYPE <br /> DIA z Zo MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) g a o~ GRADE DIAMETER OR WALL IF ANY MENT <br /> Ft to Ft TONITE FILL FILTER PACK <br /> m N coo (Inches) THICKNESS (Inches) Ft to Ft {TYPE/SlZE:} <br /> LEI55 Sill I <br /> : 6 q0IS 0 <br /> i <br /> I I <br /> 1 <br /> ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> �eologic Log t,the unnderslg ed, certify that this re ort Is complete and accurate to the best of my knowledge and belief <br /> {° Well Construction Diagram NAME 1f� ; Co�°1tir]{1��Yy1 �t"[ <br /> Geophysical Logs) WRSON FIRM OR CO OR ION) (TYPED R PRIlN,TTED) <br /> UWater Che icaI Analyses m, lt., <br /> ADDRESS <br /> Other •i — i I CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION [FIT EXISTS Signed� ° �.a i�>/tlrl �j 14 AW7��� <br /> C 57 LICENSED WATM'Wil CONTRACTOR DATE SIGNED C 57 LECENSE Nf1MBER <br /> DWR 188 REV as-Da IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />