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ORIGINAL STATE OF CALIFORNIA OWR USE ONLY — DO NOT FILL IN <br /> File wi DWR COMPLETION REPORT <br /> of_j__ Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. a4�00 9 6 5 3 LATITUDE�11LONGITUDE El <br /> Date Work Began Ended <br /> �..... Local Permit Ag S �CA a LA I.r C-0 . L&Al+1A 7EE I I I I I I 1-i <br /> Permit No. S,e�. 00 33911 2d 03 APNFIREVOTHER <br /> .. Permit Date 0 S� I <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) VERTICAL —HORIZONTAL _ANGLE _(SPECIFY) Name <br /> SAILDRIL ING /��� <br /> METHOD FLUID M Lina Addrac<4P MAtA'1Z11�eIA <br /> DEPTH FPOM �� U <br /> SURFACE DESCRIPTION �6L � Lek <br /> Ft. to Ft. Describe material, grain size, color, etc. clTv STATE 21P <br /> ELL LOCAT ON <br /> Address <br /> City L <br /> I County v <br /> APN Book Page Parcel 14— -3-3100-7 <br /> Township Range Section <br /> Latitude 'I I NORTH Longitude I I WEST <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> t LOCATION SKETCH , 9CTIVITY (�) <br /> I NORTH rY\NEW WELL <br /> MODIFICATION/REPAIR <br /> I I I- ✓v 1[ ...000 1 v T Deepen <br /> Other(Specify) <br /> Y <br /> t DESTROY(Describe <br /> PhadedoUnder"ear"GEOLOGIC <br /> IC LO Is <br /> Under"GEOLOGIC LOG") <br /> t PLANNED USES (�) <br /> WATER SUPPLY <br /> — Dame6lic Public <br /> Irrigetlon Ind to I <br /> 3 MONITORING <br /> I TEST WELL <br /> I I <br /> CATHODIC PROTECTION_ <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I SPARGING <br /> SOUTH REMEDIATION <br /> r Ill urove ar Describe Distance r f Well(rmrt Roads,Buildings, <br /> Fences,Ricers,etc.and aft. o amp.Use additional y�yer If OTHER(SPECIFY) <br /> n� _ <br /> necesm .PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL�.&/ YIELD OF COMPLETED WELL <br /> r DEPTH TO FIRST WATER .far_(FLIT BELOW SURFACE <br /> DEPTH OF STATIC�Sa0O <br /> WATER LEVEL (Ft.)8 DATE MEASURED <br /> ESTIMATED YIELD ' I (GPM) 8 TEST TVPF <br /> 1 <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (His.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative bird well's loo -term yield. <br /> DEPTHCASING (S) DEPTH ANNULAR NIATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE('') FROM SURFACE TYPE <br /> DIA. w ¢ n MATERIALI INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> [A. <br /> zO 5L GRADE DIAMETER OR WALL IF ANY MEAT TONITE FILL FILTER PACK <br /> Ft. to Ft. m N c4� (Inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (�) (TYPEISIZE) <br /> a <br /> A <br /> I I <br /> I I <br /> .ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> Geologic Log I, the undersign certify that this report is complete and accurate to the best of my knowledge and belief. <br /> l , \ Well CODStfUCtl00 Diagram NAME LGS <br /> \♦_ Geophysical Log(s) 'j'(PE SO M CDRPORPTIO ( PEN OR PRINTED 5ttt��y <br /> SoillWater Chemical Analyses /�+ .�/K„ � rxy \ q <br /> Other ADDRESS CITY STATE 2IP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed — z - 8O2 <br /> 33*_ <br /> WELL DRILLER/A ORI:"; REPRESEMATIVE DATE SIGNE C-57 LICENSE NNMBER <br /> rnnl lu REV a-as IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />