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ORIGINAL 51 AI OF CAI 1PORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> P Ig#_ of I `� lief r to I'Ivre((Ir(nl Prrnr)r d,i STATE WELL NC!STATION NO <br /> vier s Well No All No q I I <br /> ❑ <br /> Work Begin 1/'Z./`Z��� Lndecf !! -ZZ—Ze j LATITUDE tiONGITUOE � y <br /> it Petnnt AgLIJCy �i t4. �es« /L 61, /-4-,&1, �c�vcrj <br /> PLI Hilt No �#�_�1 L"l $ T Permit IJ Ite �� I`'t ` 1�u APN/TRSIOTHER <br /> ,�,�,`���yyy/// GEOLOGIC LOC' 1 WEIpL OWpN,,ERR''�� <br /> ORIENTATION (� VERTICAL _j,�HORIZONTAL _ANGLE _(SPECIFY) N lit7C_ �'�L � 7 'rD Cay M_. ./ L q S <br /> DEPTH FROM METHOD IN J"5 <br /> !S_�__ FLUID Milling address �`1`ILV �►`r►f :ivy <br /> SURFACE DFSCRIPTION <br /> FI In F, D(icreflc rnat(real gurmn tt�e color r fr CITY STATE ZIP <br /> 1 W'LI,L LOC TION <br /> Address SS CU VI' .ti <br /> 1 <br /> CUtsrity <br /> APN Book PrEge Pllcel <br /> To�tiTI5hi1� B Inge Section <br /> I Latitude I I NORTH Longitude r I WEST <br /> e DEG MtN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY J!) <br /> 1 NORTH <br /> NEW WELL <br /> e <br /> MCD! ICAYF AIR <br /> Deep— <br /> i 1 _ Olher(Specdy) <br /> I <br /> I 1 � <br /> DESTROY(Descn6e <br /> I I Procedures and Maferraes <br /> Under GEOLOGIC LOC J <br /> PLANNED USES (�) <br /> I I WATER SUPPLY <br /> 1 1 <br /> Domestic Puphc <br /> F- Irnga4 on � Sndusinal <br /> w N <br /> � < MONITORING <br /> TEST WELL _ <br /> ' 1 CATHODEC PROTECTION <br /> I I HEAT EXCHANGE <br /> 1 I DIRECT PUSH <br /> I 1 INJECTION <br /> VAPOR EXTRACTION <br /> v I SPARGING <br /> 1 SOUTH REMEDIATION <br /> Iflmhr(i( ur D(senLe UIStmu( e f`IV,d!ni),e Raa A 814d.1i l <br /> 1 PCR[L5 Rhin Or raid nitm)I a Pint1, L's( rrrlrfrtr(rnllf nplr-rf OTHER(SPECIFY) <br /> hlccwv,!j PLI'ASE BE ACCLR3TE&COWPI ET� <br /> I 1 <br /> FSATFR LEVEL & ]ISD OF CONIPLFTED WFLI <br /> I 1 DEPTH TO FIRST WATER!S�'�Ft) BELOW SURFACE <br /> I 1 DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> ' 1 ESTIMATED YIELD � (GFM)& TEST TYPE <br /> TOTAL DCM[ OF BORING KIV (FCct)C TEST LENGTH-__--(Hrs} TOTAL DRAWDOWN (Ft} <br /> TOTAL DE['TH OF COMPLETED N%'L.LI (Feet) 'May not be rep esentRrive of n wells long-rerm yield <br /> DEPTH CASING BORE (S) ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE[) FROM SURFACE TYPE <br /> DIA x z o a MATERIAL 7 INTERNAL GAUGE SLOT SIZE CE BEN <br /> {Inches} z w¢ zU GRADE DIAMETER QA WALL IF ANY MENT TONfTE FILL FILTER PACK <br /> Ft to FI m o (Inches) THICKNESS Onchas) Ft tc FI ( r) ( � ) (✓ ) (TYPE7SIZE) <br /> �yq /o +�� *' Sr tiy© y - <br /> 417 1 4e55i <br /> P <br /> I — <br /> ATTACHb1ENTS CERTIFICATION STATEMENT <br /> Geologic Log I the undersigned certify that this report+s complete and accurate to the best of my knowledge and belief <br /> — Well Construction Diagram NAME <br /> (PERSON FIRM OR P ATION) (TYPEO OR PR ) <br /> Geophysical Log(s) <br /> Soil/Waw Chemical Analyses /-/J�� C� C;�6 <br /> Other <br /> Zv ADORES5 CITY SIATE ZIP <br /> _ 1���C�_- 7y/ r <br /> ATTACH AODOIONAL INFORMATION IF IT EXISTS S'y^� ` �/'? O yI'� _• ' xs <br /> RIAUTHORIIED RCPq[$E TAiIYE DATE SIGNED C 51 LICENSE NUMBER <br /> D�itt 1Nh II Ft II v IF ADDITIONAL SPACE 15 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM <br />