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ORIGINAL STATE OF CALIFORNI- DWR USE ONLY — DO NOT FILL IN <br /> File with1 DWRWELL COMPLETION REPORT <br /> Page`of 1 Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> 15 <br /> Owner's Well No w - No 0912975_ LATITUDE LONGITUDE <br /> Date Work Began 6-2-0 nd �� i r <br /> Local Permit Agenc N " �' AV '3i �� } APN TRSIOTI <br /> Permit No y �-t3 <br /> erm>t Date -� r� n <br /> GEOLOGIC LOG `VE L OWNER <br /> qtr <br /> ORIENTATION {.�) VERTICAi. HORIZONTAL t^ANGLE _(SPECIFY) Name- <br /> DRILLING <br /> atne <br /> DEPtA <br /> FROM METHOD FLUID t 1{ �1vI 1mg�Adde�ss� krOf�l rt `�Z <br /> SCE DESCRI TION -AZ <br /> Z3 <br /> C r� 1 i i STATE ZIP <br /> FI Ft Describe material grain Size color etc\ \ `" rt ti/ ! \ \ S WELL OGAT ON <br /> ' I { l � mor' -61 <br /> I L� 5 .� ti"�% ►` ' APN Book ` <br /> C wfPaParcel <br /> Range i ' rI�'Tonsh, _r Section <br /> 33 — <br /> i y s. \� • -'+'t t�� ' \"� yLat ��.-���f'Pr!?0 I N <br /> Long_t2lit 5S4P'N I i5 W <br /> _ti \, ✓ \ \ O t��4 DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (2�L) <br /> NORTH <br /> NEW WELL <br /> MODiFICATIONIREPAIR <br /> — Deepen <br /> i i � f � � \� ~ '",� � t `�I✓rtM _ Other(Specify) <br /> DESTROY(Descnbe <br /> i t / i / �!�" �'�•; Procedures and Mafanals <br /> Under GEOLOGIC LOG) <br /> USES <br /> <-`�\k5 }' WATER SUPPLY <br /> Domestic — Public <br /> F- � Irrigation — Industrial <br /> H <br /> I i w Q MONITORINGLu — <br /> TEST WELL <br /> I <br /> CATHODIC PROTECTION <br /> i l HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> I VAPOR EXTRACTION T <br /> SPARGING <br /> 1 I SOUTH REMEDIATION_ <br /> Illustrate or Describe Distance of Well from Roads Buildings <br /> I S Fences Rmers etc and attach a=p Use adVawnal pager if OTHER(SPECIFY)_ <br /> necessary PLEASE BE ACCURATE dr COMPLETE <br /> � s <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 3 <br /> l 1 DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i DEPTH OF STATIC <br /> WATER LEVEL (FI)&DATE MEASURED <br /> 1 ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL �_� _- -- (Feet) *May not be representative of a well'r long-terns yield <br /> CASING (5) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE ✓ FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(—) <br /> DIA x z s a_ MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> {Inches) a `i' � a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft TYPEISIZE <br /> F1 to Ft m c» (Inches) THICKNESS (Inches) (✓) { } (�) ( ) <br /> I <br /> I i <br /> I <br /> I � <br /> I i <br /> ATTACHMENTS (z�) CERTIFICATION STATEMENT <br /> I the undersl ned,certify that this re o Is complete and accurate to the best of my knowledge and belief <br /> — <br /> Geologic Log <br /> Well Construction Diagram NAME 1j) Eng fm ' I "t It <br /> (PERSON FIRM OR CORPORATION) (TYPED D PRINTED) <br /> — Geophysical Log(s) Jly[ <br /> SoiVWater Chemical [ <br /> ' -Analyses Dr, 11 � � <br /> SUN m ar t[��` C 95-6y2 <br /> ADDRESS rr�•n����` 1L`,F�] CITY STATE 1y ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed5 �+�'Nr Dill,( `� _5__26_0q -710071 <br /> C 57 LICENSED WATER ELL CDN7RACTOR DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV a5 G3 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />