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ORIGINAL STATE OF CALIFORNIADWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT sTArE WELL NorsTArloN No <br /> Page I of J_ Refer to Instruction Pamphlet <br /> Owner's Well NoNo 0912977 <br /> Date Work Began - - 2 Ended 5'�"(- <br /> LATITUDE LONGITUDE <br /> Local Permit A encu u cr � ' r a l` <br /> . —,� APN/TAS/CTHER <br /> Permit No 1 Permit Date � <br /> • GEOLOGIC LOG c� rc , Fri \WE WNER <br /> ORIENTATION (r ) ✓/VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name ti j _fl <br /> ` r y <br /> DRILLING 11e;l�wvJ S�a Ma'lln' Address ota <br /> DEPTH FROM METHOD FLUID -> <br /> SURFACE DESCRIPTION ti��t �� / w CA— <br /> F1 <br /> Ft to Ft Describe material grain 82ZC color etc � CITY STATE ZIP <br /> WT <br /> E L `LOC ON <br /> i <br /> .Address �� <br /> I ; <br /> Punty �t <br /> N Book Page Parcel <br /> 'I'orvfishi _RangeSectlon� 7 <br /> A44) T Long I zy rijLl L/ _�f7y <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION <br /> NO NEW SKETCH VWEY (�} <br /> ze_ StTIL MODIFICATION/REPAIR <br /> '77'77 �lfrjy/� Deepen <br /> Other(Specify) <br /> Jr <br /> I �i� ` Y r< r, f�`� DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> USES (�L) <br /> WATER SUPPLY <br /> Domestic Public <br /> I i Irrigation _ IndusIn <br /> I I L W MONITORING <br /> TEST WELL— <br /> i I CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> DIRECT PUSH <br /> I I INJECTION <br /> I I VAPOR EXTRACTION <br /> I I <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Descnbe Distance of Well from Roads Buildings <br /> Fences Rtaers etc and attach a rm Use addttlonal paper a OTHER(SPECIFY) <br /> necessanj PLEASE BE ACCURATE&COMPLETE <br /> 1 I <br /> I Iajf <br /> vi J�_r <br /> } it Lbn WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I I <br /> I DEPTH OF STATIC 3 <br /> 5 <br /> WATER LEVEL 66 77 i (Ft)&DATE MEA5UREQS Y <br /> ' ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL 105 (Feet) 'May not be representative of a well's long-term yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE <br /> FROM SURFACE HOLE 'TYPE(2L) FROM SURFACE TYPE <br /> DIA x w o d MATERIAL! INTERNAL GAUGE SLOT SIZE C:EFBEN <br /> F14TER PACK <br /> (Inches) ' Z� a GRADE <br /> DIAMETER OR WALL IF ANY MITE FILL <br /> Ft to F[ v {inches) THICKNESS (Inches) Ft to Ft (TYPE/SIZE) <br /> Ci© 60 5 10 7 fVC.1L v q Otv b <br /> I <br /> I ' <br /> I ' <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> {,the undersigned, certify that this report Is complete and accurate to the best of my knowledge and belief <br /> ZGeosogic Log S <br /> _SG Well Construction Diagram NAME " V r' <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) , (w�� '5 CA 956�Z <br /> So:I/Water hemical Analyses `-�m rt <br /> Other ADDRESS (4!f ( CITY 55 STATE ZIP <br /> ATTACH ADD1770NAL INFORMATION IF IT EXISTS Signed,LI�CENISED WATER WEL CONTRACTOR LL� �! �+IN WIj DATE SIGNED � CI57L© SE NUMBER <br /> DWR 188 REV 05-03 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />