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r QUADRUPLICATE STATE OF CALIFORNIA r_— DWR USE ONLY — Do Nar FILL IN
<br /> For Local Requirements SELL COMPLETION REPOR'
<br /> Page)—of-_I Refer to Instruction Pamphlet STATE WELL NO./STATION NO,
<br /> Owner's Well No. ,- I No. O J 4 S 1 U
<br /> Date Work Beganr � Ended—t.+ 7 a j n n LATITUDE LONGITUDE
<br /> Local Permit Agency c < YL�",�,_ r• r,�t sy CI
<br /> L✓ Permit No. u Permit Date - z APNITRSIOTHER
<br /> ,
<br /> EOLQGIC LOG WELL OWNER
<br /> ORIENTATION (✓) VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name `
<br /> '
<br /> DRILLING SA f ,A!
<br /> DEPTH FROM METHOD ` '` `- " h +�r Mailing Address ' '� '-r r' � l , ,
<br /> FLUID— N i g
<br /> SURFACE DESCRIPTION r yy 4� , - A _ r
<br /> ` E`-T c
<br /> Ft. to Ft. Describe material, rain Size, color, etc. Oirr \ _ - STATE- - ZIP
<br /> ' WELL LOCATION
<br /> I I .Address . ' '*• - r , n T
<br /> City yr
<br /> I I County
<br /> APN Book_2 ,�_Page__! Parcel n �;
<br /> F r C ' D 12 w Township Range Section
<br /> r. n - s '
<br /> "T _ _ L'at--- I I N Long I _I w
<br /> ii.t ' _ r,,,, ' 714
<br /> DEG. MIN. SEC. DEG. MIN. SEC,
<br /> LOCATION SKETCH ACTIVITY (�)
<br /> ^ _7 r ►
<br /> 't•' NORTH NEW WELL
<br /> r :i l`y. . - .t MODIFICATION/REPAIR
<br /> Deepen
<br /> I I '+ Y ,e z - Other(Specify)
<br /> - DESTROY(Describes
<br /> Procedures and Materials
<br /> .. .. Under"GEOLOGIC LOG"
<br /> , USES(�)
<br /> 0 _ WATER SUPPLY
<br /> A — Domestic _ Public
<br /> r l"1 ,T ,
<br /> �~ F — Irrigation _ Industrial
<br /> t a T' W U).. - - ,r_ _ W MONITORING T_
<br /> TEST WELL
<br /> CATHODIC PROTECTION_
<br /> I I r , # HEAT EXCHANGE
<br /> r I F ^ DIRECT PUSH
<br /> INJECTION
<br /> I I rr r r T Tr !'S
<br /> � � +s � VAPOR EXTRACTION
<br /> r r h i A tAND llili SPARGING
<br /> ` w ` SOUTH
<br /> REMEDIATION._
<br /> I1lustrat6 or Describe Distance.of Well from Rnads,Buildia�s,
<br /> 113,
<br /> t t Fences,Ricers,etc and attach a Ina1�. Use addaional paper of OTHER(SPECIFY)
<br /> r r, , , necessary.PLEASE BE ACCURATE&COMPLETE.
<br /> I I
<br /> I I
<br /> WATER LEVEL & YIELD OF COMPLETED WELL
<br /> r I DEPTH TO FIRST WATER h (Ft.) BELOW SURFACE
<br /> r DEPTH OF STATIC r
<br /> WATER LEVEL , (Ft.)&DATE MEASURED
<br /> I I
<br /> ESTIMATED YIELD (GPM) & TEST TYPE N, P
<br /> TOTAL DEPTH OF BORING -1�} (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWNNSM (Ft.)
<br /> TOTAL DEPTH OF COMPLETED WELL (Feet) *May not be representative of a well's long-term yield.
<br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL
<br /> FROM SURFACE HOLE TYPE i FROM SURFACE TYPE
<br /> DIA. x w o a MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE- BEN-
<br /> (Inchee) ¢ o� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK
<br /> Ft. to Ft. m c» (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE)
<br /> frH n n
<br /> 2 r
<br /> } C✓ ( ' �#
<br /> I �
<br /> I r
<br /> ATTACHMENTS CERTIFICATION STATEMENT
<br /> Geologic Log I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief.
<br /> �
<br /> _,Z_ Well Construction Diagram NAMEi P IW N %h �t17
<br /> (PERSDN, I 0 COR URATIONI' PED ORE, a PRINTED)' ' " , '
<br /> Geophysical Log(s)
<br /> SoiliWater Chemical Analyses _� _, M h At V;C %N f y _ n I .+?r A� ►� i >` f r � 7 -' E
<br /> Other V .' i `CITY STATE ZIP
<br /> ATTACH AOpITIONAL INFORMATION, IF IT EXISTS. Signed—_ IJA
<br /> t! +' ie, s 1, -f
<br /> C-57 LICENS tl`VJAl'E�R 4'EiL CONTRp.C70R-} - DATE SIGNED C-5Y LILtE4'NUMhER
<br /> DWR 188 REV. M-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM
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