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ORIGINAL STATE OF CALIFORNIA <br />File with DWR WELL COMPLETION REPORT <br />Page _oi Refer to Instria-thm Pamphlet <br />Owner's Well No. No. <br />Date Work Began 1 Ended . -J9 <br />Local Pennit Agency <br />WR ONLY UU M I rILL Iry <br />STATE WELL NOISTATION NO. <br />1 11 <br />1111 <br />LATITUDE LONGITUDE <br />i I I I I I I I 1 I I I I i <br />APNITRSIOTHER <br />Permit No. <br />Permit Date <br />_ DESTROY (Describe <br />Procedures and Materials <br />— GEOLOGIC LOGWE`LL <br />Under —GEOLOGIC LOG-) <br />O'ER <br />ORIENTATION ( z) <br />VERTICAL _ HORIZONTAL _ ANGLE _ (SPECIFY) <br />Name <br />Iugation Inaustnal <br />DRILLING �,a �,, . <br />METHOD �"D \1 FLUIDVrx'� tl LLL <br />Flailing Address <br />Lu ¢ <br />w <br />DEPTH FROM <br />SURFACE <br />DESCRIPTION <br />TEST WELL _ <br />Lo <br />CITY <br />Address <br />STATE ZIP <br />WELL LOCATION <br />Ft to FI. Describe material, grain size, Color, etc. <br />( S I <br />DIRECT PUSH <br />CLI I C-0 L� <br />City <br />32D I c1 <br />ig 2-2 <br />w <br />count. <br />APN Book Page —. Parcel <br />Township Range Section <br />Latitude I I NORTH Longitude I I WEST <br />DEG. MIN. SEC. DEG MIN SEC. <br />LOCATION SKETCH— <br />N TV—NEW WELL <br />Z EgI <br />WN <br />D Y''a/ <br />�ZZ i i w Sil.'R <br />i�� i is%_ I fCJTV�L� �tt� <br />r <br />1 <br />{fe� <br />�a—me <br />MUMV <br />V <br />Ll I V, 111 :�p I U <br />500 1 JAI 'Ar Y__�G <br />I I <br />I <br />I i <br />I i <br />i <br />S Ict�— i i <br />li <br />I <br />I I <br />I I <br />TOTAL DEPTH OF BORING (Frr���� <br />TOTAL DEPTH OF COMPLETED "'ELL C(Feet) <br />1MODIFICATIONIREPAIR <br />{ 32 �` <br />L <br />Deepen <br />Other (SpeCI1y) <br />_ DESTROY (Describe <br />Procedures and Materials <br />CASING (S) <br />Under —GEOLOGIC LOG-) <br />DEPTH ANNULAR MATERIAL <br />FROM SURFACE TYPE <br />CE- BEN• <br />MENT TONTTE FILL FILTER PACK <br />PI. 10 Ft (TYPE/SIZE) <br />PLANNED USES (=) <br />r:130WATER <br />LY <br />Domes:Ic P lic <br />me Ic <br />Iugation Inaustnal <br />to H <br />Lu ¢ <br />w <br />MONITORING _ <br />TEST WELL _ <br />Lo <br />CATHODIC PROTECTION _ <br />x <br />HEAT EXCHANGE _ <br />DIRECT PUSH <br />INJECTION _ <br />VAPOR EXTRACTION <br />�J SPARGING _ <br />OU11H REMEDIATION <br />Ilhatiore or Dexr)lx• Distm+rr rrf IVr(1 ff sn i &nrls. Bnrldingr. <br />Fenlxa. Rieem etc. and attarh it ru ip. l sr nrhlitlolml Lurlx r if OTHER (SPECIFY) _ <br />neremary- PLEASE BE ACCURATE & CO.fPLET;<. <br />WATER LEVEL & FIELD OF COMPLETED WELL <br />DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br />DEPTH OF STATIC <br />WATER LEVEL � � (Ft.) & DATE MEASURED <br />. <br />ESTIMATED YIELD ' _1_ D (GPM) & TEST TYPE 9=0 <br />TEST LENGTH (His.) TOTAL DRAWDOWN (Ft.) <br />May not be represmrarre of a well's long -reran yield. <br />DEPTH <br />FROM <br />FROM SURFACE <br />BORE - <br />DIA. <br />(Inches) <br />CASING (S) <br />DEPTH ANNULAR MATERIAL <br />FROM SURFACE TYPE <br />CE- BEN• <br />MENT TONTTE FILL FILTER PACK <br />PI. 10 Ft (TYPE/SIZE) <br />TYPE(') <br />Wz a MATERIAL I INTERNAL GAUGE <br />ills GRADE DIAMETER OR WALL <br />LL (Inches) THICKNESS <br />SLOT SIZE <br />IF ANY <br />(Inches) <br />FI. to Ft. <br />)c <br />I <br />v 2Z o Lk <br />Lo <br />s <br />x <br />Isis, <br />o 2_QXX <br />32D I c1 <br />10%0 <br />i c X ) 11 <br />s(oo <br />I/ <br />PEAC <br />i <br />r— ATTACHMENTS (!) <br />CERTIFICATION' STATEMENT <br />_ Geologic Log <br />_ Well Construction Diagram <br />_ Geophysical Log(s) <br />SoilIwater Chemical Analyses <br />I, the undersiiggneed, certify that <br />NAME �Ni—a I! <br />report is complete and accurate to the best of my knowledge and belief. <br />PRWTEDI <br />CITY <br />___ Other ADDRESS Ci <br />ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br />WELL DRILLER/AUTHORIZED REPRESENTATIVE 1 <br />o ILL 11 1. Ie AnniTlno"Al eaarc Ie 11iccnen I I= AICVT rnnteerM mvCl V t.0 ls.IQC CICn cno&a <br />STATE ZIP <br />