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TRIPLICATE STATE ar CALIFORNIA DWR USE ONLY - oD NOT FILL IN <br /> 9wrter"s Copy ,LL COMPLETION REPORT <br /> • Page I o - 1 Refer to IrlStrllctiun Pnitipiiiett STATE WELL NO.ISTATION NO. <br /> Owner's Well No. ks :1 1 No. 731078 � ❑ <br /> Date 1ltgrk Be4D I + , Endcd C` " LATITUDE LONGITUDE <br /> >f - <br /> Local Permit Agency , I <br /> _ , r , 1�t <br /> - 11. ,,. <br /> L Permit NlO, P'] lIt Date <br /> APN17RSYQTHER <br /> , <br /> GEOLOGIC LOG WELL 0117NER <br /> r <br /> ORIENTATION (.�L) ,VERTICAL _HORIZONTAL _ANGLE —(SPECIFY) Nal]➢(; - <br /> DRILLING <br /> DEPTH FROM <br /> METHOD FLUID Mailing Address <br /> SURFACE DESCRIPTION <br /> Ft. to FL Du-T(:rihr. nrrtlerirtl, grain size, colot-, eft:. STATE ZIP <br /> WELL LOCATION <br /> Address <br /> Crnlnty <br /> 4` T APN Book Page Parcel <br /> Trnvnship ) Range f— _Section f - <br /> I <br /> Latitude /6 i't NORTH L.(117�r1tU Cl t: IZ WEST <br /> IJEG. MIN, SEC r' EG. MIN. SEC. <br /> LOCATION SKETCH AC'TWITY (2�) <br /> 1 i-.• ` j w NORTH NEW WELL <br /> MODIRCAT{ONIREPAIR. <br /> I [ i ! 3 f• �� rl l"( : Deepen <br /> r i t Other(Specify) <br /> _--"DESTROY(Describe <br /> {1 - Procedures and Materials <br /> I I Under"GEOLOGIC LOG') <br /> PLANNED USES (:) <br /> I I. WATER SUPPLY <br /> Domestic — Public <br /> I I Irrigation _ Industrial <br /> F � <br /> w ¢ MONITORING — <br /> 3 W <br /> TEST WELL <br /> CATHODIC PROTECTICN <br /> I I HEAT EXCHANGE <br /> I t DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGING <br /> I I SOUTH REMEDIATION a <br /> 111ustrate ur-Describe Distance if Weli fivin Brads,Builrlhigv, <br /> I I Fences,Rioan,ere rt <br /> uin ntfach rr Inap. use,addiriunnf reltcr if OTHER(SPECIFY) <br /> necc.ymny.PLEASE BE ACCURATE v COMPLETE. <br /> I I <br /> WATER LEVEI, & YIELD OF CONiPLETED WELL <br /> I � <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE t <br /> I I <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (FI.)&DATE MEASURED <br /> ESTIMATED YIELD ' {GPM) & TEST TYPE <br /> TOTAL DEhTII OF BORING (Feet) TEST LENGTH (Hrs.) TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPT Ff OF CONIPLEf'ED WELL (Feet) "11'fnp not be leprrsentaritr of n 2 e1!'s long-tarn yirld. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE <br /> BORE- <br /> FROM TYPE FROM SURFACE TYPE <br /> DIA. Y z a MATERIAL! INTERNAL GAUGE SLOT SIZE - CE- $EN- <br /> (Inches) g a �� J GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft, to Ft. Ft. to F[.' {TYPE/SIZE <br /> rn 0 va LL (Inches) THICKNESS (Inches) II ( �) (�) (�) ) <br /> I C <br /> I i <br /> I <br /> I F <br /> 1 1 � <br /> 1 r <br /> ATTACII\fENTS [2L) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned, certify that this report is complete and accurate to the best at my knowledge and belief. <br /> — — <br /> _ Well Construction Diagram NAME{r. �"�'1L'� t T�°] �_x I'%-• �'+ _r <br /> �ERS(1N, FIRfN, OR <br /> Geophysical Log{s) -CORPORATIDNI CIYPED OR"PRIN'fEJ} `•-��^' <br /> ,,� <br /> SoiiA/Vater Chemical Analyses >_ F f 3 S { <br /> ADDRESS y CITY STATE ZIP <br /> Other t-.'I-; ..,ice / f <br /> ATTACH ADDITIONAL INFORMATION, 1F IT EXISTS. Signed <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE -'` DATE 51GNED C=57 LICENSE'Nl1M8ER <br /> DWR I" RE\'. 11-9; IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />