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STATE OF CALIFORNIA - -t' DWR USE ONLY —. Do NOT FILL IN <br /> ORIGINAL <br /> File with DWR °,j� LL COMPLETION REPORT STATE WELL No.rsTATION No. <br /> Page�of ( M ( refer rn Nro tr O 9�otj FarV ltit6 <br /> Owner's Well NO. LATITUDE LONGITUDE <br /> Date Work Began II 0 Ended' l '� <br /> Local Permit Agency 5 A N O.A VIN 'C �H D APNrrRstoTHER <br /> S 5 S Permit Date _ <br /> Permit No. 0 2� � " <br /> GEOLOGIC LOG `:WI,LL OWNER <br /> GovNS`�` Q� 5;g0 '6`A' u.iN <br /> ORIENTATION VERTICAL _ —HORIZONTAL _ANGLE _(SPECIFY) Na1T12 t F <br /> DRILLING y �N,11 C ` ( �- 7 L'I?`_. y `NV� <br /> METHOD �1 5 V FLUID l4 Q N ` iVIai.ibg AddeGSs_ <br /> DEPTH FROM DESCRIPTION 0 = N Z <br /> SURFACE ,; - STATE ZIP <br /> FL to FL Describe matern , g <br /> alrhi.n sire, color, etr cE t?' a {EI LOC T[ON <br /> T <br /> ;City <br /> " , SAN 'T4RMIN <br /> zCOuntys` <br /> APN Book :=:Page_19 Parcel 0 1 <br /> H/ LL W i Q y +, Ell, r TowiTsEitip Range Section <br /> Q V -L_� �' l'1 C�S.'` Lat• N Long <br /> _, - � r REG. MIN. SEC. DEG, MIN. - SEC <br /> 0,'; P1k S H' LOCATION SKETCH ACTIVITY '(1) <br /> 5 �:L (T l NORTH _ NEW WELL <br /> EE qq <br /> e T: i V LL+4`. MOOIFICATiONIREPAIR <br /> Deepen <br /> Olher(Specity) <br /> i -��„� SIT V,+ /q,N A L� WELL DESTROY'{t7escrrbe <br /> f ('' { �I �t Procedures and Materials <br /> ai, *.. iJ � W JI ,� ] L� 1 LA � USF$n(e✓')GEOL OGfC COG") <br /> t Ij LYE A <br /> I L w A TT A G� o WATER SUPPLY <br /> i Q TLS 0 TRL � Y _ Domestic � Public <br /> i L y-' {^ f t * lrngafion — Induslriaall- <br /> i r 1. YV r 'ya, weir � Q MONITORING�L <br /> CE ' \J V 5.. _ C, -. TEST WELLT�EM <br /> _L v CATHODIC PHOTECTION <br /> HEAT EXCHANGE <br /> p DIRECT PUSH <br /> -7� <br /> { , { HY C W - INJECTION _ <br /> 4 V 1{I N C, AA / K t V E VAPOR EXTRACTION— <br /> I i H S X L T AND _ -..G�, .+.:, SPARGING — <br /> Vy� �i `-, (( SOUTH REMEDIATION_ <br /> '1- �`� `M ,r'` Illustrate or Describe Distance.of Well f`.r6m Roads,Buik7in�x, <br /> �, A Fences,riivars,etc.and attach a neap Use afhAtianal PaPC1 if OTHER(SPECIFY) <br /> 1, �r A necessary,PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER 10 11 (Ft.) BELOW SURFACE <br /> , t <br /> 1 - - DEPTH OF STATIC I - <br /> WATER LEVEL�! {FS.)&DATE MEASUREO T Q <br /> 1 ESTIMATED YIELD - -N A (GPM) & TEST TYPE N A <br /> _ TOTAL DEPTH OF :BORING `� (Feet) TEST LENGTH_-y-""'L-_(Hrs.)TOTAL DRAWDOWN N A ;(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 10 (Feet) May not he representative ofa well's long-tetyn yield. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE(,—) <br /> DIA. y� w a MATERIAL 1 '.INTERNAL GAUGE SLOT SIZE CE- BEN FILTER- <br /> (Inches) ¢ a� J GRADE DIAMETER OR WALL IF ANY Ft. to Ft MENT TOWTE FILL ' (TYP.EISIZEK <br /> Ft. to Fl .v cam p (Inches) THICKNESS (Inches) ✓ ,� _ <br /> o s vc sct 10 o :. <br /> zv v c 7 S C.H 40 . 0..0 0 <br /> zo ✓ it3 SANQ <br /> El <br /> ATTACHMENTS (2L) CERTIFICATION STATEMENT <br /> / Log is <br /> Geolo I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> �L <br /> Geologic TOSEPH RAMAL-t� Fort ASL lir.: tL AbA_F 000401 <br /> Well Construction Diagram NAME <br /> (PERSON. FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> MtgCj4AtjQ1SF WAY , A M o N b SPR 1 N G S,~QA 95619 <br /> Soil/Water Chemical Analyses <br /> Other S ! E PLA14 ADDRESS CITY <br /> STATE ZIP <br /> ATTACH ADDl7fONAL INFORMATION,!F 1T EXISTS. Signed - l <br /> • C-57 LICENS WATER WELL CONT CTOR DATE SIGNED 0-57 LfCENSE NUMBER _ <br /> DWR 188 REV. (1s-03 IF ADDITIONALirPACE IS NEEDED. USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 70836 <br />