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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements -ELL COMPLETION REPOR' I I I I I I I I I 1 <br /> Page_ofRefer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. 0927008 <br /> Date Work Began . Ended LATITUDE LONGITUDE <br /> Local Permit Agenc t ,� �,� _r cwt- x <br /> < APN/TRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) _� VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING Mailing DEPTH FROM METHOD • - FLUIDS , g Address <br /> —---- <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain .size, color, etc. ITr SL4TE ZIP <br /> WELL LOCATION <br /> Address <br /> City <br /> County <br /> APN Book Page Parcel <br /> Township Range Section <br /> Lat ., N ung,` <br /> DEG. MIN. 5 C. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> i NORTH NEW WELL <br /> ' MODIFICATION/REPAIR <br /> — Deepen <br /> — Other(Specify) <br /> Y DESTROY(Describe <br /> / Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> USES I(-) <br /> WATER SUPPLY <br /> (\ I 7 Domestic - Public <br /> F Irrigation _ Industrial <br /> 3 w MONITORING <br /> TEST WELL <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> i SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> i Fences,Rivers,etc.and attach a map. Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. _ <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> t ESTIMATED YIELD' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING +1 _(Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representative of a well's long-term yield. <br /> DEPTHCASING (S) DEPTH ANNULAR MATERIAL <br /> HOLE <br /> FROM SURFACE BORE- TYPE(-) FROM SURFACE TYPE <br /> DIA. Y w a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- FTONI�E <br /> FILTER PACK <br /> (Inches) Z w zr a GRADE DIAMETER OR WALL IF ANY MENT FILLFt. to Ft. m 0j zi (Inches) THICKNESS (Inches) Ft. to Ft. (�) (TYPE/SIZE) <br /> o m <br /> i <br /> ATTACHMENTS 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 /> _ Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />