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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements 7,LL COMPLETION REPOR'. 1111111111111 <br /> Page of i Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. 0927010 <br /> Date Work Began i I Ended _ LATITUDE LONGITUDE <br /> Local Permit Agency <br /> APN/TRS/OTHER <br /> Permit No. Permit <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (z�) 4t VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Name` <br /> DRILLING MailingAddress <br /> DEPTH FROM METHOD !_ FLUID _ - <br /> SURFACE ES <br /> -. <br /> Ft. to Ft. Describe material, grain .Size, Color, etc. CITY STATE Z'F' <br /> WELL LOCATION <br /> Address <br /> City <br /> ' <br /> County r=� <br /> APN Book Page Parcel <br /> Township Range Section <br /> Lat _ N Long r, I W <br /> i dEG. _MINI- EPi; DEG. MIN.' SEC. <br /> LOCATION SKETCH ACTIVITY (2L) <br /> NORTH _"NEW WELL <br /> vs, MODIFICATION/REPAIR <br /> Deepen <br /> ------ _ Other(Specify) <br /> ' DESTROY(Describe <br /> Procedures and Materials <br /> ' Under"GEOLOGIC LOG") <br /> 1, USES(2L) <br /> y 1� WATER SUPPLY <br /> Q" <br /> Domestic'— Public <br /> �t Irrigation _ Industrial <br /> � H <br /> w <br /> W MONITORING,.T <br /> i X TEST WELL <br /> f"III CATHODIC PROTECTION <br /> ' HEAT EXCHANGE <br /> I_ J <br /> DIRECT PUSH <br /> !� <br /> INJECTION— <br /> VAPOR EXTRACTION <br /> i I SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, <br /> i Fences,Rivers,etc.and attach a nu 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 /> ESTIMATED YIELD' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (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 /> DEPTH BORE- <br /> CASING (S) DEPTH ANNULAR MATERIAL FROM SURFACE HOLE TYPE(—) FROM SURFACE TYPE <br /> DIA• Y w o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- <br /> BE FILTER PACK <br /> (Inches) Z o� CL GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft. to Ft. m v c>> (Inches) THICKNESS (Inches) Ft. to Ft. J J (TYPE/SIZE) <br /> I ' <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 /> Well Construction Diagram NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED)' <br /> _ Geophysical Log(s) <br /> Soil/Water Chemical Analysesz� - -- <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-51 LICENSE NUMBER <br /> DWR 188 REV.05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />