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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY <br /> 17]7 NOT FILL IN <br /> File with DWR OL COMPLETION REPOR <br /> PageRefer to instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. N°,7 0 9 6 5 2AT� ❑ <br /> Date Work Began Ended_ LATITUDE LONGITUDE <br /> Loeal Permit AgencTy� 5 fj So u J <br /> Permit No. '.-A 6033 g91 Permit Date K/2-0 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) 19VERMCAL H RIZONTAL —ANGLE _(SPECIFY) Name lTrX <br /> DRILLING It7.00 <br /> DEPTH FROM METHOD ��.FLUID Mailing Address Ylry� Ay,r- <br /> SURFACE DESCRIPTION <br /> Ft. to FL Describe material, grain size, color, etc. "' STATE ZIP <br /> Address T ELL LOCA ION <br /> City <br /> fn County�4 �1 <br /> APN Book Page Parcel <br /> Township Range Section <br /> r r Latitude I I NORTH <br /> Longitudet WEST <br /> I I DEG. MIN. SEC. DEG. MIN. SEC. <br /> r LOCATION SKETCH CTIVITY (�) <br /> NORTH . NEW WELL <br /> I r <br /> MOOI FICATIAIR <br /> Deepen <br /> Other(Specify) <br /> A-ofr DESTROY(Describe <br /> PrectuI t and Matrials <br /> Under"GEOLOGIC <br /> LOG") <br /> PLANNED USES (v) <br /> WATER SUPPLY <br /> r _ Domestic Public <br /> WIrrigation Xlnduetrial <br /> I r � w MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION_ <br /> HEAT EXCHANGE <br /> r DIRECT PUSH <br /> r INJECTION <br /> VAPOR EXTRACTION <br /> r <br /> SOUTH SPARGING_ <br /> t REMEDIATION_ <br /> Illustrate e'Descrihe Distance of well(mm Rw�ds,Buildings, <br /> Fences,Ricers,etc,end attach a nm t. $e mlditinnnl))nNer if OTHER(SPECIFY)_ <br /> necesvnnJ.PLEASE BE ACCCZL4�E&COMPLET . <br /> ==M <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER�vt(Ft.) BELOW SURFACE <br /> DEPTH OF STATIC[ <br /> WATER LEVEL (Ft.)&DATE MEASUREDESTIMATED YIELD '� (GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWNFt.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of rs well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE <br /> DIA. TYPE <br /> w ¢o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Ft. to FL <br /> (inches) 5 ¢ e. GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> m to o' S (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> I <br /> I <br /> I <br /> r <br /> I r <br /> ATTACHMENTS (ze) CERTIFICATION STATEMENT <br /> Geologic Log y <br /> I,the undersigned,Certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME W <br /> Geophysical Log(s) (PERSO , FIRM, OR DORPDRATI M (TYPED OR PRINTED) <br /> SOII/Water Chemical Analyses �-!.i �eIIAJ,Ge-` R- Q�Q"1 <br /> Other AGGRESS '//)�/ CITY STATE l ZIPP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> WELL GRILLER/ ORIZED REPRESENTATIVE GAi SIGNE Cd7 LICENSE NUMBER <br /> DWR Lss HEN. a-IT, IF ADDITIONAL SPACE IS NEE D, USE NEXT CONSECUTIVELY NUMBERED FORM <br />