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ORIGINAL STATE OF CALIFORNIN DWR USE ONLY - DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page_L o1 ��+}` Refer to Instruction Pamphlet STATE WELL NO ISTATION NO <br /> Owner's Well No ! 'k)— 10 ` NO 0912979 <br /> LATITUDE LONGITUDE <br /> Date Work Began S`2C���_ _ En ed 5' �'O �� � J) <br /> Local Permit Agency TJA 3ou4r� .��� ti V I s Ill'yil 1'4 1 ti <br /> g y �_ �` APN/TRSIOTHER <br /> Permit No � <br /> � 3� Per <br /> �� PermitDate _._.,• — <br /> GEOLOGIC LOG �/#{}`" QELP OWNER <br /> ORIENTATION (�) _VERTICAL —HORIZONTAL —ANGLE _(SPECIFY) Nam <br /> DRILLING FLUID <br /> METHOD i ;Mailinb Add4ass <br /> DEPTH FROM Y r - ,.. G 4't✓� <br /> SURFACE DESCRIPTION �� rl STATE ZIP <br /> F1 to Ft Describe material grain size Color etc`� ���"0_,,�Al/ \ , <br /> Add, <br /> -7 <br /> WELL LOCATIO <br /> I IGe. C j 11�` r L ?� �C_ ib. 4P ' ;.= Leey-COA-, ^' - itounty> J��� Uvi <br /> r r 4` �' �� ��'� APN Book �� Page Parcel <br /> To hiRangeRange Ry' Lo g n 33 - <br /> __ 12-1,S3142?0 b W <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ASI IVITY (�1 <br /> NORTH ✓NEW WELL <br /> <x-L, <br /> � /�,+ ,,AA MODiFICATIONIREPAM <br /> x-L, 711 �v�A/� — Deepen <br /> — Other(Specify) <br /> I i <br /> �w' lr ? <br /> _ DESTROY(Describe <br /> Procedures and Matenafs <br /> Under GEOLOGIC LOG) <br /> USES (2! ) <br /> WATER SUPPLY <br /> 1� Domestic — Public <br /> I I Irrigation — Industrial <br /> I I ¢ MONITORING <br /> I I <br /> TEST WELL <br /> I I CATHODIC PROTECTION - <br /> HEAT EXCHANGE_ <br /> I I - <br /> DIRECT PUSH — <br /> INJECTION <br /> i I VAPOR EXTRACTION— <br /> I I <br /> SPARGING— <br /> SOUTH REMEDIATION — <br /> Illus"e or Describe Distance of Well from Roads Buddings <br /> Fences Rtf m etc and attach a map Use additional paper of OTHER(SPECIFY) — <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> I I <br /> I+ fi WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I I <br /> DEPTH OF STATIC I5s C:WATER LEVEL (Ft)&DATE MEASURED c. <br /> ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING {Feet) TEST LENGTH (Firs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL ( -.--(Feet) *May not be representative of u well's long-terns yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(',.) FROM SURFACE TYPE <br /> DIA z ¢ MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> w o FILTER PACK <br /> (Inches) w z� a GRADE DIAMETER HI WALL (i ANY MENT TGNITE FILL <br /> Ft to Ft m cgo (Inches) THICKNESS (Inches} Ft to Ft (� (�) (�) (TYPEISiZE) <br /> � kf <br /> l t3 -D-2, 1 ; % <br /> 0 1109 <br /> I <br /> ' I <br /> TACHMENTS (2:�) CERTIFICATION STATEMENT <br /> I the undersl ied certify that this repo I�coTC_. <br /> te and accurate to the best of my knowledge and belief <br /> Geologic Log I JI(}WellConstruction Diagram NAMEg c � <br /> (PERSON FIRM OR COVICA <br /> RATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) 33�� LM rR � `� 550 C� .0r (�� CAIff <br /> odlWater C emicalLAnalyses �" C.. Imo✓ <br /> Other 1 l ADDRESS 1, {'�4 `y CITY �}C STATE ` l�ZI-P7 <br /> ATTACH ADDITIONAL INFORMATION IF 1T EXISTS Signed�1���4fti� LTJ ��"`J`� �1 �V 1 <br /> C 51 LICENSED WATER WELL NTE TGR DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 05 03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />