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!i <br /> DWR USE ONLY — DO NOT FILL IN <br /> QRIGiNAL U STATE OF CALIFORNIA <br /> File with DWR WELL COMPLETION "REPORT <br /> Refer to fastnretiott Pamphlet IF STATE WELL NC.ISTATNON NO. <br /> Page of 1uf W- f ❑ ❑ <br /> Owner's Weu No. -SA No. 746 5 2 0 �€ <br /> � VU l� LATITDDE LONGITUDE <br /> Date Work Began !� Ended J/ <br /> Local Permit Agency 5P v ��� N.1/ilEM�et�. � APN/TRSIOTHER <br /> } Permit No. m Q :� 1 �- Pennit Date ^"Z , <br /> I GEOLOGIC LOG 3 `-WELL OWNE <br /> cm <br /> ORIENTATION (.�L) VERTICAL _HORIZONTAL __ 'AiJGLE, {SaEclFIY) Name <br /> MHElnla� ;FLUID.,` MaTltnrg Ass G <br /> DEFrH FROM Ir.- r` <br /> ' suRFacE DESCRI TION - <br /> FL la Ft Describe material, grain Si=e color, etc '_C7 •-.'`�,l ''�. �,,) STATE ZIP <br /> WCL LOCATION <br /> `' •Address <br /> ' I I <br /> i G'ounty. <br /> i AFN Book Page Parcel <br /> ToVvcisliip Range Section <br /> l l { �� I 1 NO <br /> Longitude I <br /> DEG. MIN. SEI WEST <br /> ) <br /> 'lt'Flde C. DEG. MIN. " SEC. <br /> It 4 LOCATION SKETCH ACTIVITY ('') <br /> NORTH NEW WELL <br /> l I _ MODIFICATIONIREPAIR <br /> I 1 Deepen <br /> Other(Specily) <br /> �,,. <br /> I - ✓ ' DESTROY l (Describe i Procedures and Materiels <br /> 1 1 _ Under"GEOLOGIC LOG") <br /> 3 SS PLANNED USES (4) <br /> a , <br /> I P WATER SUPPLY <br /> l , _ Domestic Public <br /> Irrigation Industrial <br /> I I 3 I, w MONITORING <br /> w cJ' I k TEST WELL�.. . <br /> I� CATHODIC'PROTECTION <br /> HEAT EXCHANGE_ <br /> _ Itpy DIRECT PUSH_ <br /> F l INJECTION <br /> l I S !k VAPCR EXTRACTION <br /> l �f SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of FVeu from Roads,Builrllrlgs <br /> F l Fences,Ricers,atc.and attach a riap. Use additional ppaper,i� OTHER(SPECIFY) <br /> acccxsary.PLEASE BE•ACCU)RATE&COMPLETE. <br /> T rRC � <br /> $ WATER LEV�E�,& YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE - <br /> DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> ESTIMATED,YIELD" (GPM) &TEST TYPE, <br /> } TOTAL DEPTH OF BORING (Feet) TEST LENsarH (Hrs.)TOTAL DRAWDOWN (FL) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's lore -term yieU J <br /> I} DEPTH BORE_ CASING (S) I) DEPTH ANNULAR MATERIAL <br /> lI FROM SURFACE HOLE TYPE( I 'FROM SURFACE TYPE <br /> DIA- x a MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN <br /> . (Inches) zr DIAMETER OR WALL IF ANY FILTER PACK <br /> � GRADE MENT TCNITE FILL <br /> Ft to Ft m ca c� (Irmnes) THICKNESS (Inche's) Ft. to Ft. IT'rP 7 <br /> N W f=) (�) (�) <br /> r <br /> li r <br /> I} r <br /> ATTACHMENTS (.�L) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> — Geologic Log <br /> I' <br /> Well Construction Diagram NAME ) <br /> (PERSON, FIRM, OR CORPORATION). {TYPED OR PRINTED) <br /> _ Geophysical Log(s) i} <br /> SofVWater Chemical Analyse <br /> Other Tj ADDRESS 'F CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION. IF IT EXISTS. Sr9 I <br /> WELL mILLE.IJ.ORIZED REPRESEMATIVE DATE SIGNED C-51 LICENSE NUMBER <br /> n <br /> DWR IM REV. 11-Ir IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />