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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page__._f__.of j_ Refer to Instruction Pamplaet STATE WELL NO!STATION NO <br /> Owner's Well Nom � -A i'it-} No 0912976 <br /> LATITUDE LONGITUDE <br /> Date Work Began AA �" <br /> Loco] Permit A ency - G �'"` kf I r.Perms No .00-3-7 1q7 Per 1t Date ApNTRSlOTHER <br /> { <br /> J/ GEOLOGIC LOG , rL�r \W ELL. NER <br /> ORIENTATION ( �) t!VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING �� h {~ <br /> METHOD �1:ill�rt) �k�[U4Zf FLUID N�1a]-I>xlg AC1Clre5S ►•i <br /> DEPTH FROM "J""'� Il all \ 4 •"/'ti <br /> SURFACE DESCRIPTION �'� <br /> � r; rw+n r / \ 1_/' _ <br /> Ft to Ft Describe material, grain size COIOr etc�� �\ C � /°l <br /> jj ` W L LOCATION �STATE <br /> ZIP <br /> U1 'Add <br /> AC A 0 <br /> //(t <br /> affCounty"e Jamsio 3 VIN <br /> r^ koL { APN Book Page Parcel <br /> T'ov-,Wm-110LL RaSection 3) - } <br /> , rAl; . G � J <br /> Lawl 5 A S {.' '� �"� Lat.57a�19 7A N Long ��2/, 59, W <br /> i i �.�,yt��ttt f��''r S 1 t,.✓� ,1` ^', y DEG MSN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�} <br /> I , L �a 1({SIJIw \ t ✓ t ,} Y -��Wi` NORTH 1✓ <br /> NEW WELL <br /> MODIFICATION/REPAIR <br /> f <br /> 14.N Deepen <br /> cit VICIADESTROY Ili <br /> { L� <br /> Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> � <br /> USES (2:�) <br /> WATER SUPPLY <br /> Domestic Public <br /> t„ <br /> Irrigation tnd ustnal <br /> H <br /> W ¢ MONITORING- <br /> LLI <br /> TEST WELL <br /> I CATHODIC PROTECTION— <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I I SPARGiNG <br /> SOUTH <br /> REMEDIATION <br /> Illustrate or Descnbe Datance of Well from Roads Buildmgs <br /> I I Fences Rlt-en etc and attach a map Use additional paper of OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> � I <br /> r I DEPTH TO RRST WATER (Ft) BELOW SURFACE <br /> r DEPTH OF STATIC [/ <br /> WATER LEVEL (F1)&DATE MEASURED <br /> ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet TEST LENGTH (Hrs) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-term yield <br /> DEPTH BORE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE('' ) FROM SURFACE TYPE <br /> DIA x INTERNAL GAGE SOT SIZE CE BEN <br /> (Inches) Z w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft m cc $� (Inches) THICKNESS {Inches) FI to Ft (TYPE/SIZE) <br /> to Vlr 5jL, LID <br /> r7 Ib 0 a Z I <br /> I <br /> I I <br /> I I <br /> ,ITTACHMENTS (!) CERTIFICATION STATEMENT <br /> I, the undersi led, certsfy that this repo Is complete and accurate 10 the best of my knowledge and belief <br /> . .+.'eolagll:Log r�1,,,� <br /> T Well Construction Diagram NAME rny,IgA r TY%C, <br /> (PERSON FIRM OR CORPORATION) (TYPED OR-PRINTED <br /> _ Geophysical Log(s) 3S0 1�;�?at 4.7E ` S5� P �' <br /> olUwater Chemical Analyses V QI �(�L r I* <br /> VOther 51 s'+r'\ ADDRESS �tD <br /> ( r CITY (��j STATE ZIP <br /> ATTACH ADD1TlONAL lNFOAMATlON 1F IT EXISTS 'Signed "WCi`�[ W {f`}`� <br /> 11 C 57 LICENSED WATER WEL CONTRACTOR DATE SIGNED C 57 LICENSE NUMBER <br /> DWR 188 REV 05 03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 76836 <br />