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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY <br /> File with DWR — Do Nor FILL IN <br /> L COMPLETION REPOR <br /> Page�of� Refer to Instruction Pamphlet STATE WELL N0./STATION NO. <br /> Owner's Well No. No.709651 <br /> Date Work Began , Ended 11 --�-` I�❑ <br /> LATITUDE ❑ LONGITUDE <br /> " Local Permit Agency _L <br /> LSA-nd e ,J (� e zral f� <br /> Permit No. - LO* CIO 5 >11 l Permit Date 9, 20 63 APN/TRS/OTHER <br /> GEOLOGIC LOG <br /> ORIENTATION (✓) VERTICAL HO ZONTAL _ANGLE <br /> DRILLING —(SPECIFY) Nalne WELL OWNER <br /> ^^ <br /> DEPTH FROM METHOD Ate FLUID Mauling Address-�S.tL <br /> SURFACE SCRIPTION <br /> Ft. to Ft. DC.SCYIhC 7IIotCr((rl, pram Size, Color, etc. CITY STA E ZIP <br /> ' W LL LOCATI <br /> I r Address GO <br /> r city_lsdyo <br /> r APN Book page t Parcel_ Lei'3 3�If co 7 <br /> Township Range Section <br /> I I <br /> Latitnde r NORTH Longitude_ r WEST <br /> DEG, MIN. SEC. DEG. MIN. SEC. <br /> r LOCATION SKETCH CTIVITY (�e) <br /> NORTH <br /> r I / NEW WELL <br /> r t L — MODIFICATION/REPAIR <br /> rs�- "��Yo62 �� _ Deepen <br /> III'''fff Other(Specify) <br /> Y <br /> 1 DESTROY(Describe <br /> Procedures and Materials <br /> r Under"GEOLOGIC LOG'J <br /> I PLANNED USES <br /> WATER SUPPLY <br /> Domestic Public <br /> r W _ Irrigation Industrial <br /> w <br /> 3 w MONITORING . <br /> I I <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> r DIRECT PUSH <br /> r INJECTION <br /> VAPOR EXTRACTION_ <br /> SOUTH SPARGING <br /> Blr <br /> or Desnribe LlIquece of Woll l'mur Pornds,Buildings, REMEDIATION <br /> r icers,etc rtnd nttnc6 a amp Ilse additional roper if OTHER(SPECIFY) <br /> r .PLEASE BE ACCURATE&COMPLET�WATER LEVEL & YIELD OF COMPLETED WELL <br /> O FIRST WATER�(Ft.) BELOW SURFACE <br /> F STATICEVEL .6'4L(Ft)8 DATE MEASUREDED YIELD• (GPM) A TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) NGTH_(Hril TOTAL DRAWDOWNTOTAL DEPTH OF COMPLETED WELL (Feet) ot be representative of a well's long-tnTn yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL SURFACE HOLE TYPE() FROM SURFACE <br /> DIA.hzx w O¢ lo MATERIAL/ INTERNAL GAUGE SLOT SIZE TYPE <br /> Ft, to FC (Inc ) ] eu O� a GRADE DIAMETER OR WALL IF ANY CE- BEN. <br /> or cco M (Inches) THICKNESS (Inches) Ft. to Ft. MENT TONITE FILL FILTER PACK <br /> (TYPE/SIZE) <br /> I <br /> I <br /> r <br /> r <br /> l <br /> 11 <br /> ATTACHMENTSO CERTIFICATION STATEMENT <br /> X Geologic Log I, theundersi ned,Lertify that <br /> this report is complete and accurate to the best of my knowledge and belief. <br /> 1XWell Construction Diagram NAME W <br /> — Geophysical Log(s) p 1rcrcSDyN, FIRM, OR•CyD,RPORATION) (TYPED 6R PRI ED) <br /> Soit/Water Chemical Analyses _ .y�G..t i'AL✓�Tna _ gam- M qw7 4 <br /> Other ADDRESS CITY STATE ZIP <br /> P <br /> IT <br /> ATTACH ADDITIONAL INFORMATION, IF EXISTS. Signed 4 eo <br /> WELL DRILL r THDRIZED REPRESENIATIVE OAi SIGNED C-57 LICENSE NUM ER <br /> nM'R las NEv. a=r IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />