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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 <br /> Page_of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 1 No. 0927013 <br /> Date Work Began k F,nded (1 "_� LATITUDE LONGITUDE <br /> Local Permit Agency A a_( <br /> Permit No. Permit Date 1-2 l l--1 j <br /> APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) ✓VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Name`," <br /> DRILLING Mailing Address <br /> DEPTH FROM METHOD_"r,1 L t`-\a J /��L F-�1FLUID L 1, , �� g <br /> SURFACE DESCRIPTION CITY , S7A E ZIP <br /> Ft. to Ft. Describe material, grain size, color, etc. WELL LOCATION <br /> Address <br /> n_�4_ - �• City <br /> County <br /> APN Book 4 Page Parcel <br /> Township Range Section <br /> Lat�'_� T!-1 Z a. N Long I, W <br /> DEG. MIN.- _S C. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (x�) <br /> NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> — Deepen <br /> Other(Specify) <br /> _ DESTROY(Describe <br /> _ Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> USES(�) <br /> WATER SUPPLY <br /> Domestic _ Public <br /> Irrigation _ Industrial <br /> 4 a MONITORING 1� <br /> TEST WELL_ <br /> CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> t rv' SPARGING_ <br /> SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Builrliu;. <br /> Fences,Rivers,etc.and attach a me Use additional paper OTHER(SPECIFY)_ <br /> necessary.PLEASE BE ACCURATE d�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)B 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. C.-__ <br /> p a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- FILTER PACK <br /> (Inches) � a GRADE DIAMETER OR WALL IF ANY MENTJTOENNI�E FILL <br /> Ft. to Ft. o LL (Inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (2:L) (TYPE/SIZE) <br /> i <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 />