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TRIPLICATE STATE OF CALIFORNIA _r— DWR uSE ONLY — DO NOT FILL IN <br /> Owner's Copy ILL COMPLETION REPORT <br /> P-*/ of Refer to htslrrretion Pamphlet III, . STATE WELL NO./STATION NO. <br /> Owner's Well No. �'�'� �:� (! No'731075 <br /> �310 7 <br /> ❑ <br /> Date \'N'Ol'k 13ega17 / n[lL(1 14 L'L• LATITUDE LONGITUDE ❑ <br /> twill Local Permit Agency `r rr ..;1•, v , i.t ".tom n (�(t :fry f i; fel r!, <br /> Permit No,= r- t_ =�'� Permit Date `{ 2-LC t3L APN/TRSiQTHER <br /> GEOLOGIC LOG SVELI. OIVN1•".R <br /> ORIENTATION (.!L) —VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Nanie '' r {i Ll <br /> DRILLING <br /> DEPTH FROM METHOD FLUID N'lailing Ad(lress -<1` ,� d11 .=r rf+ <!1 <br /> SURFACE DESCRIPTION <br /> R. to FI. <br /> !)user-rile material, grain 3i;za, Coior, etc. CIN STATE ZIP <br /> I I IVELL .LOCATION <br /> Address t �t r <br /> COL713#\, "'6 1'• f-lf lt,, 1 <br /> L Al'N Book Page _ 1'al-ccI . <br /> r �- r. • i t r+ s�.t,. fit! -?# To\\nTship Rail e rcC Section <br /> r+ is• rr r'. #^ ` Latitude f'-' 111 NORTH I,ongitttde ! 1 Z'S 1 s WEST <br /> DEG. MIN, SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�n) <br /> f / NORTH — NEW WELL <br /> MODIFICATION/REPAIR <br /> m.�,7 i'�- ►e .:'�11 S. al t:.r - f: .. , <br /> "rE { Deepen <br /> 4. jo' fii. 'C.T I. �fit.l — Dee <br /> Other(Si <br /> I I . <br /> — DESTROY(Describe <br /> I - Procedures and Materials <br /> Under"GEOLOGIC LOG'J <br /> PLANNED USES (t ) <br /> I I WATER SUPPLY <br /> Dcmeslic — Public <br /> _ Irrigation _ Industrial <br /> I I W Nt4MONITORING <br /> LJ <br /> I I TEST WELL <br /> I CATHODIC PROTECTION <br /> I I <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> 1 r <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I $PARGING <br /> SOUTH <br /> I I REMEDIATION <br /> Illustrate a+-Describe.Di-wonce of Rel!fmol Runde,Biliirlin d I I Fences,Ricers,rte.and attaelr a ntn111.Useaddifinnad pal OTHER(SPECIFY) <br /> necessanj.PI,F,ASE RT ACCUtIATF Z COSIPLETE. <br /> I I <br /> NATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> r I DEPTH TO FIRST WATER {Ft.) BELOW SURFACE <br /> r DEPTH OF STATIC ! <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I r <br /> ESTIMATED YFELD ' (GPM) & TEST TYPE <br /> TOTAL DEM-- OF B011ING (Fce1) TEST LENGTH {Hrs.)TOTAL DAAWDOWN (Ft.) <br /> TOTAL, DEPTH OF CO.MPLEITE.D WEILL (Deet) `tray riot be representative ofor a:ell's long-term)veil. ' <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE(�) FROM SURFACE <br /> HOLE TYPE <br /> DIA. x z s a MATERIAL 1 INTERNAL GAUGE SLOT SIZE �'ENT <br /> EBEN- <br /> (Inches) s o� a GRADE DIAMETER OR WALL 1F ANY TDNITEFILL FILTER PACKFt. to Ft. c� (Inches) THICKNESS pnchesJ )Ft. to FI: �) (�) (�) <br /> I 1 <br /> r i <br /> r i <br /> I� <br /> � I <br /> I I <br /> I I <br /> ATTACUMENTS l CERTIFICATION STATEMENT <br /> Geologic Log <br /> I, the Undersigned, certify that this report is complete and accurate to'the best of my knowledge and belief. <br /> — � � <br /> ,_ s-,l�. <br /> Wel!Construction Diagram NAME W 121'121'1J R "� �s'ttr,Z•% �� <br /> Geophysical Log(s) (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> — <br /> Soil/Water Chemical Analyses (' Ir lI r, (�, R. + ( tl'• < j.1 C <br /> Other '41 iZ r' l�C,?s ADDRESS 1 CITY , STATE ZIP <br /> I �f <br /> ATTACH AD { rDITIONAL WFORMATION, IF IT EXISTS. Signed - " - � C ��--•!'.��1-'`� '`l"� i /r «r I1 �G� r <br /> WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED C-57 LICENSE NUMBER <br /> DWR ISS REV. Il. IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> r <br />