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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page—Lof-L- R fer to Instructio)z Pamphlet STATE WELL NOISTATION NO <br /> Owner's Well No 3 No 0912978 <br /> Date Work Began !�i�'0Ended S_011-@ LATITUDE LONGITUDE <br /> Local Permit Agency �� '�"� ^ APNlTRSroTHFRI <br /> • Permit No 6 o31 i La Penn it Date It-13A) <br /> GEOLOGIC LOG a` oW L OWNER <br /> ORIENTATION (!) <br /> ." <br /> °J_` VERTICAL —HORIZONTAL ANGLE _(SPECIFY) Na171B <br /> DRILLING 1. - lv1 y �1Address .' r �"t rs <br /> DEPTH FROM METHOD jyl7ii�ta�+'� FLUID - �, J <br /> SURFACE DESCRIPTION `� f i .� .fes 3 <br /> Ft to Ft Descrtbe material grain st;e color ets`\ '� el�,� � � � �� STATE ZIP <br /> W L LOCATIO <br /> + f. .-,Address !i' i q w- Adi 5 <br /> Q An <br /> r *� �%ZA / * APN Booke Sec <br /> Paged Parcel <br /> TownSb �7aS ]Ran Sect-ion 32 <br /> i tiL,att' '!�` IS I?, g N Long ZI 74. W <br /> SEC DEG MIN SEC <br /> LOCATION SKETCH TIVITY <br /> NORTHNEW <br /> (�) <br /> NEW WELL <br /> ' ' "'` • �{�� t�1 V r Saye s`( ^LAA MODIFICATIONIRr=PAIR <br /> +fJl - Deepen <br /> — Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under GEOLOGIC LOG) <br /> USES (.!:L) <br /> WATER SUPPLY <br /> Domesuc Public <br /> F <br /> irrigation Industrial <br /> t- <br /> ' LU <br /> W MONITORING— <br /> I I TEST WELL <br /> i I CATHODIC PROTECTION <br /> HEAT EXCHANGE.� <br /> I I <br /> DIRECT PUSH <br /> • I I INJECTION <br /> ' I VAPOR EXTRACTION- <br /> 1 I SPARGING <br /> + ; SOUTH REMEDIATION <br /> Illustrate or Desenbe Distance of Well from Roads Bu>Id=ngs OTHER(SPECIFY) <br /> Fences RtLen etc and attach a se additional paper zf )— <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> r i <br /> a i IY� _ i iI 1L1 WATER LEVEL & YIELD OF COMPLETED WELL <br /> U'Ar 4 ip` (J DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC -7 q <br /> WATER LEVEL ` (Ft)&DATE:MEASURED � y� <br /> I s ESTIMATED YIELD (GPM) & TEST TYPE <br /> TOTAL DEPTH OF BORING ( 2e) TEST LENGTH (Hre) TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "May not be representative of a well's long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE HOLE TYPE() FROM SURFACE TYPE <br /> DIA x a MATERIAL! INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) w a 4 GRADE DIAMETER OR WALL IF ANY FILTER PACS( <br /> Ft to Ft MENT TONITE FELL TYPEISIZE <br /> Ft to Ft m o (Innes) THICKNESS (Inches) ( ) <br /> s 3 <br /> si� L4 'S <br /> 57� 605 <br /> I <br /> I I <br /> I <br /> ATTACHMENTS (.!:L) CERTIFICATION STATEMENT <br /> I,the undersigned certify that this re ort Is complete and accurate to the best of my knowledge and belief <br /> eologic Log <br /> Well Construction Diagram NAME 5 � 5 ��V 1 on <br /> tr <br /> Geophysical Log(s) <br /> (PERSON <br /> � FIRM OR CDRPORATION) (TYPED OR PRINTED) f/�� <br /> ___. Geophysical <br /> ater Chemic i Analyses 5330 `-`I.wPYti'1 � �f. �yiik 5� mgfm FOA _ C 1 q��z _ <br /> -Other ADDRESS ^~ CTY STATE ZIP <br /> Signed �Bcz�r f,illr C�. 521-o� u� <br /> ATTACH ADb1TfONAL INFORMATION 1F IT EXISTS C 57 LICENSED WATER ELL 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 78836 <br />