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QUADRUPLICATE STATE OF CALIFORNIA r— DWR USE ONLY — Do NOT FILL IN <br /> For Local Requirements ,ELL COMPLETION REPOR' <br /> Page! I of Refer to Instruction Pamphlet STATE WELL NO-/STATION NO. <br /> Owner's Well No. I'1 W No. 0948167 <br /> Date Work Began t l L Ended-11 0 10 g LATITUDE LONGITUDE <br /> Local Permit Agency SAM T'A Q V i H ( u i �j� V:410 <br /> �1 J�` � Sl APN/TRSIOTHER <br /> Permit No. Permit Date 10.__ 3 � <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) NameDRILLIN <br /> y �ilV <br /> DEPTH FROM METHOD A u � FLUID N O N L Mailing Address ['1011 S C S it 5 A V ti N tl <br /> suRFACE DESCRIPTION fl A (! <br /> F. to Ft. <br /> Descr)(7e material, !train size, Golor, etc. CITY STATE ZIP <br /> .Address : - t IVF' L LO ATI <br /> � k L t1 <br /> CitvE C Y <br /> County' S A'' -70AQVIN <br /> APN Book R Page _Parcel N <br /> Vi1 L W A 5 C)�E C� �Y Township Flange Section <br /> COLA -OAI.LLIN(r THE ENTME ` Lat. _ _ I I N Long W <br /> Pt O R F h V L E AND to �, � WITH H � DEG. MIN. SEC. DEG. MIN. SEC, <br /> AA r- 1 t'� �a�l t 1 tA1 �h LOCATION SKETCH ACTIVITY (�) <br /> C C " W I tII`�G ,fig 1 , II'`i-��V NORTH <br /> NEW WELL <br /> ' ' ky� {� ir - '" v MODIFICATIONIREPAIR <br /> — Deepen <br /> i - _ Other(Specify) <br /> STAW UY ANO Ali. WLLI <br /> _ DESTROY(Describe <br /> - i <br /> —A S i N,�r 'A' Al t R.!A L <br /> 1 A E 5 [ t S(T F PLAN <br /> LAN Procedu <br /> res and Materials <br /> Under"GEOLOGIC O <br /> xEVp rANNVLAR USES(�) <br /> Al AND ra7r ch WAS USES GHFo <br /> WATER SUPPLY <br /> i ry F 1 E - h 1' AND <br /> D T Li t 0 _ Domestic Public <br /> f� L. �{ rV FILLEDV1'� sY 1/er�t1 Fry? �F+ lt/Il Irrigation Industrial <br /> tib'+}���. W f't 7 /S 4�r Y'y1,,�i ri_H fqf Q ' U) MONITORING <br /> 4, Ee�,y `�N't lJV VT Y J 1 N 1T TEST WELL <br /> 1 I\L 1_I I CATHODIC PROTECTION— <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> -' T { SUrtfpCE 4YA5 hLSjQRir INJECTION_ <br /> CV111NG A I ' x 1' 50VA <br /> ��`` J� (� j AND <br /> } n^� VAPOR EXTRACTION <br /> I ty,�yl 1 H E A T P�{H�A I fit, A N iJ AIC � SPARGING <br /> I �� THF F i Y C. t'i L NT WITH 1 H SOUTH <br /> �. REMEDIATION <br /> =1 f- 1� [� Illastrate or Describe Distance of Well from Bnarls,Buildings, <br /> \0 M A V f E U `1 A 7�N A Fences,Ricers,etc and attach a rnap- V se a&lilional paper if OTHER(SPECIFY) <br /> necessary,PLEASE BE ACCURATE 'cr COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> i DEPTH TO FIRST WATER 5 03 (Ft.) BELOW SURFACE <br /> i DEPTH OF STATIC p i <br /> WATER LEVEL �'�(Ft.)&DATE MEASURED <br /> ' r ESTIMATED YIELD - _NA_. (GPM) &TEST TYPE-1 A �. <br /> TOTAL DEPTH OF BORING G (Feet! TEST LENGTH !*A (Hrs.)TOTAL DRAWDOWN NA (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 2—0 (Feet) May not be representative afar well's long-term yield. <br /> DEPTH BORE <br /> CASING (S) DEPTH ANNULAR MATERIAL FROM SURFACE HOLE TYPE(—) FROM SURFACE TYPE <br /> DIA. Y = C a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> Inches z �+"'+ z� a DIAMETER OR WALL IF ANY FILTER PACK <br /> (inches) GRADE MENT TONITE FILL <br /> Ft. to Ft. m cgs (Inches) THICKNESS (Inches) Ft. to Ft. 7YPEISIZE) <br /> 20 vVC 2 5r_t4 4o © , oto 3 1 ►�41�1 t} 3 SaAD <br /> I <br /> I <br /> ATTACHMENTS I ---- 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 /> .ys ✓ Well Construction Diagram NAME 7©S E P H R A M A i Fm ALL III f L At!,A N Q O N M L N T <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> Soil/WaterChemical Analyses b I 16 u <br /> U VW 0 1 S E WAY,, DiAMOND S PM1 N G S. A � ` i'Zi 179 <br /> ADDRESS CITY STATE <br /> ZIP <br /> Other ' fit pit-Au <br /> ATTACH ADDfT10NAL INFORMATION, IF IT EXISTS. Signed <br /> C-S�FD WATER WELL CONTRACTOR DATE SIGNED C-51 LICENSE NUMBER <br /> DWR 188 RFV. I IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />