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TRIPLICATE STATE OF CALIFORNIA ;— DWR USE ONLY — DO NOT FILL iN <br /> Owne'r's Copy COMPLETION REPORT <br /> Sage—I—Of_]_ Refer fu Instruelinn PnlnjlhlcrSTATE WELL NOJSTATION NO. <br /> 0%vner's Well No. )`I r; 7 No. 731076 F]Date�-Vork Began v Isll dee] } ,< LAT17UDE LONGITUDE <br /> I Loexl Permit Agi;ncy i �. /.,.. v I ! 1 l ;. �,• _ M l+a i't.s <br /> Permit NO. / �• IF �tmit } APN/TRSIOTHER <br /> _ l�a.c <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> 'DRILLING <br /> DEPTH FROM <br /> METHOD FLUID Mailing Address r) <br /> - - - <br /> SURFACE DEISCRIPTION j <br /> FL to Ft. DcscYi.i material, tiraio sj:zc, COlr11', Cil:. CITY STATE ZIP <br /> �1`.FLL LOCATION <br /> Addreas ;). t _ , <br /> Citv <br /> I I n <br /> AIIN Bod_`i Parcel <br /> �. Torvnshih rr 0 Range Section <br /> Latitncle '1 �> 1 r/F NORTHt LnitrfitTa.Ee 1 c WEST <br /> BTG.Mehl. `-SEC. "'MSEC, <br /> t t: \ LOCATION SI{I;TCII AC.TIVITV (�) <br /> .r NORTH — NEW WELL <br /> MODIFICATION/REPAIR <br /> I ISf' _ '�' - { Y[. �; ,-i,: � !,r r•- Deepen <br /> I IOther iI <br /> j. <br /> DESTROY(Describe <br /> - Procedures and Mafarials <br /> Under''GEOLOGIC LOG') <br /> PLANNED USES () <br /> I I t WATER SUPPLY <br /> Domestic Public <br /> I I F hfl9fltlon Industrial <br /> F <br /> I I W w MONITORING- <br /> I I TEST WELL— <br /> 1 I CATHODIC PROTECTICN— <br /> HEAT EXCHANGE <br /> I I <br /> 1 r DIRECT PUSH— <br /> I I INJECTION— <br /> I I VAPOR EXTRACTION— <br /> I I SPARGING— <br /> SOUTH REMEDIATION— <br /> jilhsrlrrle or-Dh rlibe Visrnwe of Well fimn Rnnds,Build"'gs, <br /> �i OTHER SPECIFY <br /> I I !%rums,tit:;crs,ere.nnrl«)Incl+rt nrrtlIf. sr ndrlrlinnal 11nrprr f (SPECIFY)— <br /> necrrsrlry. PLEASE Bl:'ACCURATE '&COSIPLETE. <br /> WATER LEVEL & Y.11,LD OF CO2NIPLTTEI) TELL <br /> I I . <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> f <br /> ESTIMRTED YIELD ' (GPM) & TEST TYPE <br /> TOTAL DEPTH OF 1I011INC (heel) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPT-fl OF COMPLETED WELL, (Feet) *Alta),not he repi-erentnrive of e well's long-tenor yirld. <br /> DEPTH CASING (S) DEPTH I ANNULAR NIATERIAL <br /> FROM SURFACE BORE- TYPE(} FROM SURFACE TYPE <br /> HOLE <br /> DIA. w ii MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (inches) z w zP a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. m m OQ (inches) THICKNESS (Inches) Ft. to Ft. ( ) <br /> TYPEISIZE <br /> (—') 1(2) <br /> I <br /> I I <br /> I <br /> I I <br /> I I <br /> ATTACHMENTS (Y) CERTIFICATION STATEN[ENT <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 Logs) <br /> — Soil/Warer Chemical Analyses 20. <br /> ADDRESS CITY STATE rip <br /> Other .i c <br />- ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signe <br /> WELL DRItLERlAUTH 12ED fPRESENTATIYE DATC.SP ED C-57 LICENSE NLIMBER <br /> t vtt't; tss IIEv. 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />