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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Pae pf Refer to Instruction Pamphlet STATE WELL NO/STA71ON NO <br /> Page No <br /> 0912980 <br /> Owner's Weil No <br /> Date Work Began Z'Dq , Tended —IDLI <br /> LATITUOE LONGITUDE <br /> Local Permit Agenc S'I^��Uti �'" '�-'� ct� a <br /> • Permit No �C� I i-t IZ Permit Date 4-113'D APNlTRSlOTHEft <br /> �7 <br /> ./ GEOLOGIC LOG f _; pT LL OWNER <br /> ORIENTATION {✓) ✓ VERTI AL _HORIZONTAL _ANGLE _(SPECIFY) Name i ,•� I� <br /> DRILLING <br /> DEPTH FROM 11 a METHOD `7r FLUID z `vii A fi d, i$` �' r r <br /> SURFACE DESCRIPTION \l "✓yA,V�9 <br /> FI !o Ft Descrtbe material grain size (_olor etG��` ���'CIS( �` \ l \ t TATE MP <br /> `` y r ��+ ;\� t \ 1 WEL LOCATION e4 it. <br /> 1 ,/ �J /� ~Address y _ ��.1r� { <br /> ' t ,t v ` L 1c .[~.}I�}, �,/' ~yGa'i � ! 4L1 A I �l f i ;: C" <br /> ii U `�✓, j,� `t < ./1 C:oun yl Q 1 ifit <br /> APN Book Page Parcel <br /> rah "#� ✓ <br /> Towns hlp,1as Range Section.33 <br /> ,L`At'37,713a`i U 31 N Long 171,,53(,�38� W <br /> DEG T� SEC T DEG MIN SEC <br /> s LOCATION SKETCHTIVITY (2L) <br /> `y_� l �(�� NORTH NEW WELL <br /> � �� 1, /� �\ ✓ v t MODIFICATI eEPAIR <br /> Deepen BP9T1 <br /> — Other(Specrfy) <br /> ` ` � DESTROY(Describe <br /> Procedures and MalMaienals <br /> Under GEOLOGIC LOG) <br /> USES () <br /> WATER SUPPLY <br /> F Domestic Public <br /> I I <br /> IrngaVon Indus,n <br /> ' ' 3 w MONITORING <br /> TEST WELL <br /> I I CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> i DIRECT PUSH_ <br /> I I <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Illustrate or Descnbe Deatance of WeU from Roads Bu,ldangs <br /> Fences Raters etc and attach a nu Use addatienal paper f OTHER(SPECIFY) <br /> necessary PLEASE BE ACCURATE d+COMPLETE <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE: <br /> DEPTH OF STATIC <br /> WATER LEVEL � u (Ft)&DATE MEASURED <br /> '7 ESTIMATED YIELD (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING f 0 (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL ID __(Feet) r May not be representative of a well's-long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> TYPE <br /> HOLE <br /> FROM SURFACE BORE (_'' ) FROM SURFACE TYPE <br /> DEA Y = C a MATERIAL I INTERNAL GAUGE SLOT SIZE GE BE <br /> Inches z w zr a DIAMETER OR WALL IF ANY FILTER PACK <br /> F1 to Ft ( ) GRADE F! to Ft MENT TONITE FILL YPEISIZE <br /> m 1 (Inches) THICKNESS (inches) ( / / (T ) <br /> � <br /> ISO LO I pvc -5c D ' <br /> S32 L Pv ,(40 Li 14 <br /> -16I <br /> I <br /> I I <br /> I I <br /> ATTACHMENTS (1�:) CERTIFICATION STATEMENT <br /> I the undersl ned certify that this ITT <br /> rt is complete and accurate to the best of my knowledge and belief <br /> Geologic Log <br /> Well Construction Diagram NAME f -5 t t s <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) A la' Vr, � t556 C <br /> oil/Waterl+C,,hemi al Analyses ! S fZI <br /> Other ilk ADDRESS/4 1.,� 1 -I�(Y !_ CITY STATE 1 ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Srgned <br /> 9,cC� IWR.yd,>.,tfl L (,�} �'� <br /> C 57 LICENSED WATER ELL CONTRACTOR DATE SIGNED C57 LICENSE NI.IMREtLj <br /> DWR 188 REV 05 03 IF ADDITIONAL SPACE 13 NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 78836 <br />