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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR OLL COMPLETION REPOR <br /> Page J_of� Refer to Instruction Pnmpblet STATE WELL !T :]Owner's Well No. '-' No.Date Work Began ab , Ended 709649LATIrup Local Permit AgCCennncy arJ _ nQiA'n7 (n + "fPermit NO. U,—' •� 00 33 B ( B APN/TOTHE <br /> Permit Date s� 0.3 <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (::) X VERTICAL HORIZONTAL _ANGLE — SPA P�/ <br /> DRILLING (SPECIFY) N81pe_7t'l� <br /> DEPTH FROM METHOD FLUID :Nailing Address .Zd( N Won_ 1d a <br /> SURFACE DESCRIPTION 15.4 <br /> Ft. to R. Describe material, grain size, color, etc. ... CA STATE ZIP <br /> r ELL LOCATION <br /> Address '7�D0 /V _ int ALw <br /> cryr I <br /> County q4 <br /> r I <br /> APN Book Page Parcel 33 100 <br /> r I <br /> Township Range Section <br /> I I <br /> Latitude NORTH Longitude WEST <br /> DEG. MIN. SEC, DEG. MIN. SEC. <br /> LOCATION SKETCH <br /> CTIVITY (v) <br /> NORTH NEW WELL <br /> r SGS A ( y Lst.� MODIFICATION/REPAIR <br /> 4 31YC s Deepen <br /> r ' Other(Specify) <br /> I I <br /> DESTROY(Describe <br /> Procedures and Materials <br /> I Under"GEOLOGIC LOG") <br /> I PLANNED USES (v) <br /> WATER SUPPLY <br /> Domestic Public <br /> y r Irrigation Industrial <br /> LJ <br /> MONITORING <br /> TEST WELL_ <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> r DIRECT PUSH <br /> r r INJECTION_ <br /> VAPOR EXTRACTION <br /> SOUTH <br /> SPARGING <br /> REMEDIATION_ <br /> Illuvtrrda or Dueribe Distance of lVel!imm Ronr/�dr-,� <br /> ' r Fences,fticers,Nc.and nttncb n mop se additioOTHER(SPECIFY) <br /> necevson�.PLEASE BE ACCURATE d+COMPL <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> r r DEPTH OF STATIC �� <br /> WATER LEVEL .oV (Ft.)8 DATE MEASURED-08 <br /> ESTIMATED YIELD' (GPM) a TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH_(Hrs.)TOTAL DRAWDOWN <br /> TOTAL DEPTH OF COMPLETED WELL (R.) <br /> (Feet) May not be representative of well's long-tome yield. <br /> DEPTH BORE- CASING (S) DEPTHMINNULARA 'ITEYR MATERIAL <br /> FROM SURFACE HOLE TYPE('—') FROM SURFACE <br /> DIA. >< z ¢o a MATERIAL/ INTERNAL GAUGE SLOT SIZE Ft. to Ft. (Ircnes) m GRADE DIAMETER OR WALL IF ANY ACKin <br /> Ilncnes) THICKNESS (Inches) Ft. to Ft. E) <br /> t <br /> I <br /> r <br /> I <br /> I <br /> I <br /> I <br /> I <br /> ATTACHMENTS (v) CERTIFICATION STATEMENT <br /> Geologic Log I,the undersyi(,gnned,c[e�rytlfy that this report is complete and accurate to the best of my knowledge and belief. <br /> XWell Construction Diagram NAME ," •EX"' ! AIAN-r�{4..O <br /> Geophysical Log(s) (PER , OR CORPORATION) (TYPED On rninmur <br /> SoiMWater Chemical Analyses nay `(j4Y`�� ��C ._ <br /> ADDRESS <br /> — Other CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed 01- 00`2 3'F' <br /> WELL GRILLE DRIZED REPRFSENTATIVE DAi SIGNED C-W LICENSE NUMBER <br /> Do'R 148 RRY. a-e% IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />