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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY - DO NOT FILL IN <br /> File with DWRWELL COMPLETION REPORT <br /> Page I I a Refer to Instruction Pamphlet STATE WELL NO/STATION No <br /> Owner's Well No f" f 5 No 0912981 <br /> Date Work Began �"�-�� E dLATITUDE LONGITUDE <br /> id �" �� ll RR `` ' <br /> Local Permit A enOY '•Siiy 10 CR(L,111 ;1 A Ayyo.1i�1j h 4�A UP T <br /> -M'll�iJ� <br /> Permit No I Z Permit� Date ! ,! ApNrrRS/OTHER <br /> GEOLOGIC LOG. {`rte r/ lowE WNER <br /> ORIENTATION (✓) -/VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING <br /> i r k D! <br /> DEPTH FROM METHOD Ili 11L r�+- ^ FLUID r >Mailin � d�ess� ,A <br /> SURFACE DESCRIPTION ���� r 1 STATE ZIP <br /> Ft to F[ Describe material grain stze color etc t D \ e W I L DATION <br /> A.Address !fir ' (f <br /> YY� �~X 5 <br /> l � } d 1J <br /> I s "D \� J � / }` o � � <br /> APN Book `� Page p��� Parcel <br /> J) Townshipl, 9,5 Range�i7��Section — <br /> '� 1'rat'7' N Long �ZrrS.�if(aZ/,7 w <br /> -=jI r DEG MIN SEC DEG MIN SEC <br /> r`C�1� `�\ \ ✓ ��r LOCATION SKETCH ArQ'IIVITY f ) <br /> NORTH NEW WELL <br /> I i ~F } -��✓ [�,a n MODIFICATIONIREPAIR <br /> — Deepen <br /> 1 ! _ Other(specify) <br /> I I � <br /> DESTROY(Describe <br /> ProceI E ` I ,!t �•�,�/' rtt� \t%�'? <br /> Under daGEOLOG res and Materials <br /> } <br /> USES (Z ) <br /> WATER SUPPLY <br /> Domestic �.. Public <br /> �r <br /> Irrigation �.. Industrial <br /> H <br /> I i Lu w MONITORING <br /> I I <br /> TEST WELL <br /> i I CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> I <br /> DIRECT PUSH <br /> INJECT3ON <br /> I I VAPOR EXTRACTION <br /> I <br /> SPARGiNG <br /> I ISOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads Buildings <br /> Fences Rmers etc and attach a map Use additional paper if OTHER(SPECIFY) _,..,.. <br /> necessary PLEASE BE ACCURATE&COMPLETE <br /> I 1 <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I I <br /> DEPTH OF STATICq� <br /> WATER LEVEL f, (FI)&DATE MEASURED <br /> I I ESTIMATED YIELD (GPM) & TEST TYP£ <br /> TOTAL DEPTH OF BORING P (Feet TEST LENGTH (Hrs)TOTAL DRAWDOWN (FI) <br /> TOTAL DEP'T'H OF COMPLETED WELL (Feet) *May not be representative of a well'r long-term yield <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE_ FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(—) <br /> DIA z ¢ d MATERIAL INTERNAL. GAUGE SLOT SIZE CE <br /> w o FILTER PACK <br /> (Inches) � w z� a GRADE DIAMETER OR WALL IF ANY MENT JT(BEN <br /> ONITE F3EL <br /> Ft to Ft m v c�� (Inches) THICKNESS (inches) Ft to Ft (TYPE/SIZE) <br /> I <br /> I � <br /> I I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I the unders gned, certify that this re ort IS complete and accurate to the best of my knowledge and belief <br /> aL <br /> Geologic Log /!4 ` F nn <br /> _3 /Well Construction Diagram NAME] } �VIrpyt l (. --- -— <br /> (PERSON FIRM Oft ORPORATION) ITYP D OR PRINTED) (/ R <br /> Geophysical Log(s) / lll�t{,�o (jf t1V2 it � - C( ?fm Palk /'n + f <br /> �ySolVWater Che Ical Analyses ['Q �f I \STA b <br /> Other ' <br /> ADDRESS ! CITY STATE _ IP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS Signed <br /> C 57 LICENSED WATER W CONTRAC OR pATE SIGNED :C:57 l[JL}CVfNSE IUMBER <br /> DWR 168 REV 0503 IF ADDITIONAL SPACE IS NEEDED USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 79836 <br />