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I <br /> QUADRUPLICATE STATE OF CALIFORNIA — DWR USE ONLY — DO NOT FILL IN <br /> for Local Requirements .. .,:LL COMPLETION REPORT I I I I I I I I I I <br /> Page of Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well No. j t r - No.7 4 6 510 1 1 1 1 ❑ ❑ <br /> Date Work Began Ended ` LATITUDE LONGITUDE <br /> Local Permit Agcnc\ + '' ` <br />" Permit No. ' d APN/TRS/OTHER Permit Date �" - � <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION _VERTICALL —HORIZONTAL —ANGLE —(SPECIFY) NameDRILLING <br /> ���� K �'/•' r (" <br /> METHOD FLUID Mailing Address f l 7 <br /> D TH FROM <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY STATE ZIP <br /> WLL LOCATION <br /> City -rAddress <br /> --1 ( fi <br /> County <br /> APN Book Page Parcel <br /> Township Range Section <br /> I Latitude I I NORTH Longitude I VVES T <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH _ NEW WELL <br /> ' MODIFICATION/REPAIR <br /> Deepen <br /> Other(Specify) <br /> Ole <br /> DESTROY(Describe <br /> Procedures and Materials <br /> Under"GEOLOGIC LOG') <br /> '—J <br /> PLANNED USESO <br /> WATER SUPPLY <br /> Domestic Public <br /> F � _ Irrigation _ Industrial <br /> U) <br /> MONITORING <br /> TEST WELL_ <br /> i CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION— <br /> SPARGING <br /> SOUTH REMEDIATION <br /> Ilhr.strate or Describe Distance of Well ffrom Roads,Buildings, <br /> Fences,Rivers,etc.and rdtach a to �. Usc a I Ill' I aper if OTHER(SPECIFY) <br /> ncceswi PLEASE BE ACC6aA&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> e WATER LEVEL (Ft.)&DATE MEASURED <br /> t i <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING Frrl TEST LENGTH (Hrs.)TOTAL DRAWDOWN (R) <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 <br /> BORE- <br /> FROM TYPE( ) FROM SURFACE TYPE <br /> DIA. cwn <br /> a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) � a DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MENT TONITE FILLFt. to Ft. LL (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> o (�) (2L) <br /> I I <br /> i <br /> ATTACHMENTS (.�L) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> _ Geologic Log /[ <br /> Well Construction Diagram NAME ! l <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/Water Chemical Analyses <br /> . ADDRESS ,. CITY STATE ZIP <br /> th r <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed WELL DRILLER/AUTHORIZED REPRESENTATIVE DATE SIGNED/ C-57 LICENSE NUMBER <br /> DR'R 188 REV. 11-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />