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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR L COMPLETION REPOR <br /> Page_�_Of—/� Refer to Instruction Pamphlet STATE WELL N0./STATION NO. <br /> w <br /> Oner's Well No. '� Na 0 Q C O ❑ <br /> Date Work Began , Ended v �J LATITUDE LONGITUDE <br /> Local Permit Agency C VtN`-- Permit No. <br /> Permit Date <br /> 52 �D'3 [B 0"7 ZO /D 3 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) X VERTICAL HO IZONTAL —ANGLE —(SPECIFY) Nalne <br /> DRILLING <br /> DEPTH FROM METHOD tG FLUID Mailing Ad ess <br /> SUflFACE ESCRIPTION •CLIISr—+ <br /> Ft. to FL Describe material, gain size, talar, etc. pTY STATE ZIP <br /> r WELL LOCATIO: <br /> Address�� tF <br /> City <br /> ' County <br /> APN Book Page Parcel 14-3 007 <br /> ' Township - Range Section <br /> Latitude I I NORTH Longitude I I WEST <br /> r DEG. MIN. SEC. DEG. MIN, SEC, <br /> LOCATION SKETCHf1CTIVITY (�) <br /> 1 - �( <br /> NORTH NEW WELL <br /> SLMODIFICATION/REPAIR <br /> Deepen <br /> I _ Other(Specify) <br /> DESTROY(DescrAm <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> PLANNED USES (4) <br /> WATER SUPPLY <br /> Domestic Public <br /> N _ Irrigation Y�IndustVnal <br /> w w MONITORING �irse <br /> TEST WELL <br /> I CATHODIC PROTECTION <br /> I HEAT EXCHANGE <br /> I DIRECT PUSH <br /> INJECTION_ <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Per., or Describe d,fad,of WEU(rom Roads,Buddings, <br /> I Fences,.Ricers,etc.rtnd nttndi n n%, Use ndrlifinmd gpriper if OTHER(SPECIFY)_ <br /> necex,nnl.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER 1916 (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC �/.s <br /> WATER LEVEL 5Ft.)8 DATE MEASURED'- V/ <br /> I I <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 well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE TYPE <br /> DIA. w o¢ = MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> " (Inches) wm a0 m GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m y oo LL (Inches) THICKNESS (Inches) Ft. to FL OYPE/SIZE <br /> I <br /> I � <br /> I I <br /> ATTACHMENTS (2:) CERTIFICATION STATEMENT <br /> J eologic Log <br /> I,the unde igne certify that this report is complete and accurate to the best of my knowledge and belief. <br /> �d,� G <br /> Well Construction Diagram NAME <br /> CdGaG <br /> — Geophysical Log(s) `� (PERSON, FIRM, R GUH AORAAIIOm (TYPED D PRINTED) tIl <br /> SoiDwater Chemical Analyses �3� �r VWH �IT�"1 f�.o <br /> Other ADDRESS r CITY [/ STATE A� ZZZIP77 <br /> ATTACH A00177ONAL INFORMATION, IF IT EXISTS. Signed ! !e �V 277 <br /> WELL DRILL AUTHORIZED R ATIVE DATE IGNE C-57 LICENSE NUMBER <br /> DAVRR fax REV. n-DT IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />