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QUADRUPLICATE STATE OF CALIFORNIA <br /> For Local Requirements SELL COMPLETION REPOR' r— °WR USE ONLYFILL IN <br /> Page—I—O£_I,_ Refer to Instruction Pamphlet STATE WELL NO.ISTATION NO. <br /> Owner's Well.No. No. 0948168 <br /> Date York Began i Ended i LATITUDE LONGITUDE <br /> Local Permit Agency .6 � r. , f <br /> Permit NO. .Y ` Permit Date '! APNlTRSlOTHER <br /> y GEOLOGIC LOG ` <br /> WELL OWNER <br /> ORIENTATION (�} �L VERTICAL —HORIZONTAL —ANGLE <br /> DNILL1NG —(sPEaFY) Name <br /> METHOD - LUIDDEPTH FROM —tr . a <br /> Mailing Address <br /> SURFACE DESCRIPTION ' <br /> r <br /> Ft. to I=t. Describe material, grain size, color, etc. 5 ATti CE TIP- <br /> WELL LOCATION <br /> Address +. .: h 4 <br /> Gi <br /> ti 4 <br /> f COunty N IQ t til <br /> APN Book-N-A,- .Page_f+A Parcel�`L� <br /> „ e Township . Range Section <br /> r Lat_ I N <br /> g <br /> ' ' • r a # ] 'LM DEG. MIN. SEC. LOn DEG. I MIN. SEC. W <br /> LOCATION SKETCH ACTIVITY { } <br /> AhADNORTH <br /> A'' a - � y r — NEW WELL <br /> L°. I} ✓ti <br /> M - MODI FICATIONlREPAIR <br /> >'- rt r- _ Deepen <br /> I I <br /> Other(Specify) <br /> i <br /> I I r 9 r`" ALL 4ELL DESTROY(Describe <br /> 1 f Procedures and Materials <br /> r I `� r 1 �,� Under"GEOLOGIC LOG") <br /> Fr t �t T USES <br /> ' l 1 F/ {�} <br /> . P= ' s' A T k yf A I,I Imo] WATER SUPPLY <br /> .�,•, r �! Domestic Public <br /> I <br /> ~ I" ' H' Irrigation Industrial <br /> ( ` C F <br /> t v 1 t w N <br /> I I �, T•^t < MONITORING <br /> TEST WELL_ <br /> CATHODIC PROTECTION <br /> f <br /> HEAT EXCHANGE <br /> ' 1; (• h t't DIRECT PUSH <br /> I n q t r ! ! INJECTION <br /> r VAPOR EXTRACTION <br /> ,r <br /> t r . . + Ott r, � v SPARGING <br /> SOUTH <br /> t Illustrate or Describe Distance of Well fmna&n¢rls,Builrlin�s, REMEDIATION <br /> ' ' r Fences,Ricers,etc.and attach a nury se urlrfitianal aperelf OTHER(SPECIFY) <br /> t r necessan�.PLF,ASE BE ACCURATE Id1 COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I DEPTH TO FIRST WATER _A-l--=a— (Ft.) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL 10 (Ft.)&DATE MEASURED I <br /> ESTIMATED YIELD `--(GPM) &TEST TYPE A! A <br /> TOTAL DEPTH OF BORING in (Feet) TEST LENGTH —(Hrs.) TOTAL DRAWDOWN.-) (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL _^ (Feet) *May not be representative of a well's long-terns yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE() FROM SURFACE TYPE <br /> DIA. x w ¢o a MATERIAL! INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) g w =r a GRADE DIAMETER OR WALL IF ANY FILTER PACK <br /> ¢ J MENT TONITE FELL <br /> R. to Ff. m v c�� (Inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> R C C240 <br /> (4 <br /> I <br /> I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> _1vL Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME ^.C,1 i<7 L; }� I,/I(k (`�, i n h ?� }.� !1R ! �" <br /> g {PERS�!,"Flfifrl, CORP RATId ' (TYPED OR PRINTEDI <br /> Geophysical Log(s) <br /> SoildWater Chemical Analyses14 K h t! 1T'SI A� h f !ti 1„1 I� r O I• 1I Jt a {. i <br /> A0�3 fc� ..'I: ..:.� �— "—��- : �'�"�''. =CIT1y ��JSTATE ZIP <br /> Other x ;t t P . A 1. <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed - %• '��` ` t - - -`,f.-^ (f '�C- {) � -_ <br /> C-57 LICENSED WATER WELL CONT CWR OATE SIGNED 1-57 LICENS NUMBER <br /> DWR 188 REV. Os-Da IF ADDITIONAL SPACE IS NEEDED, USE NEX�CONSECUTIVELY NUMBERED FORM <br />