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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR NVELL COMPLETION REPORT <br /> P1gC of NrJ'r Ir+ Insire"Hun Paoilrhl,f STATE WELL NO/STATION NO <br /> D«ncx S WI-11 No . !t !• No LC`,S L_ ❑ <br /> Wosk 13e�to zl`c FI <br /> - I(1ed ///`Z 3 -C'S7 ! LATITUDE LONGITUDE <br /> c 11 Pcrrnrt Ah(nc) 5- - 4:f /L <br /> Pc"tell No �1` i Pei mit Date l I I N ` Zs�'S <br /> APNITRS/OTHER <br /> GEO1 OGIC LOG 1 �S ELL OWNER C <br /> ORIENTATION {✓) VEHTJLAL HOR12ONTAL _ANGLE _(SPECIFY) N,,n E'_ <br /> METHOD r tl FLUID NI-tilin Ad(Iress �`7k J LNa-e�►- <br /> QEPTH FROM - <br /> SURFACE DESCRIPTION C,r , Ci 0ss1 8 <br /> Ft to Ft Dfwri{7c 7nrltcrr(rl ruin sr-c CL/IUr clr- CITY STATE ZIP <br /> WEI L 1 OW!ON <br /> Address 0 VI' e <br /> City 0—� <br /> County J-z. L.r'ti <br /> APN Book Page Puce! <br /> Township R tcxge SectrOn <br /> Latitude 1 I NORTH Longitude I I WEST <br /> I DEG MIN SEC DEG MM SEC <br /> t <br /> LOCATION SKFTCII ACTIVITY (2L) <br /> NORTH NEW WELL <br /> ' Mool ICATIONlREPAiR <br /> L — Deepen <br /> I _ Other(Specdy) <br /> DESTROY(Oescebe <br /> vz and <br /> ' Urtderaures GEOLOGICrLOGs) <br /> PLANNED USES (.:L) <br /> I WATER SUPPLY <br /> DOmesnc P<Mc <br /> ' I � hugahon Industeai <br /> ~ r <br /> C MONITORING <br /> W <br /> TEST WELL <br /> t CATHODIC PROTECTION <br /> ' HEAT EXCHANGE <br /> DIRECT PUSH <br /> I , <br /> INJECTION_ <br /> VAPOR EXTRACTION <br /> ' I SPAAGING�. <br /> I I SOUTH REMEDIATION <br /> 111ucnah n+ Dcscrdr( Lhifanc-( ,f lE,ll nu,Ready 8mldul,!c <br /> o r <br /> Font,s R,aui c4r and rrllrr(Ce« it «rrrhtrrkn,r rr,«p(r rr OTHER)SPECIFY) <br /> n(ceWory PLLASF BE ACC(.RAT1E&COMPI FTE <br /> MATER LEVFI & YIELD OF COMPLETED WLLL <br /> s r DEPTH TO FIRST WATER FI) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)d DATE MEASURED <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTII DEPTH OF BORING IFccl) TEST LENGTH�_'(H"5) TOTAL DRAWDOWN {Ft) <br /> TO1A1 DEPTH OF COMPLETED WEI L —(Feet) 'May nor be rep"esnuanue of a wells Iong-teen yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR 11iATERIAL <br /> FROM SURFACE HOLE TYPFROM SURFACE TYPE <br /> DIA r w o a MATERIAL I INTERNAL GAUGE SLOT SfZE CE BEN <br /> Ft t❑ Ft f"rhes) 3 N z? 1 GRADE DIAMETER OR WALL IF ANY -NT TONI;E FILL FILTER PACK <br /> o (Inches) THICKNESS (inches) Ft Io Ft <br /> (TYPE/SIZE) <br /> DC AMLZ- <br /> ATTACHMENTS (zL) (ERTIFICATION STATENIFNT <br /> Geologrc Log <br /> [ the undersigned certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well ConSiTUclion Diagram NAME <br /> {PERSON FIRM OR ATION) f1YPED OR PRINIX) <br /> Geophysical Log(s) <br /> Soil Water Chemical Analyses <br /> ADDRESS CITY SIATE IFP <br /> 7 <br /> ArTACH A00 TIONAL WFOFA?ATION 1F 1T EXISTS Sr9ned 1z ZY&S- �/(J _ <br /> B RIAUTHUM r2ED REp RESE IAIIVE DATE SIGNED C 57 LICENSE NUMBER <br /> ups It 1`<ti Ii F\ II I- IF ADDIT#ONAL SPACE IS NEEOED USE NEXT CONSECUTIVELY NUMBERED FORM <br />