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s <br /> TRIPLICATE i t STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> Owner's Copx I WELL COMPLETION REPORT • <br /> Page of <br /> Refer to Instruction Parnphlet STATE WELL NOfSTATION NO <br /> _ _ ff 805861��++++�� ❑ ❑ <br /> Owner's Well No 4 No CJ[J 1 <br /> Date Wolk Began ) `� Ended y (' ( LATITUDE LONGITUDE <br /> Local Permit Agency _ ..rwl <br /> Permit No ' 7 Permit Dater � APNITRS/OTHER� f <br /> GEOLOGIC LOG WELL, OWNER <br /> ORIENTATION (t) VERTICAL —HORIZONTAL —ANGLE ANGLE —(SPECIFY) Name Z 1 � I{ � I- �k ,t, "N <br /> DRILLING <br /> DEPTH FROM <br /> METHOD FLUID Mailing Address <br /> SURFACE DESCRIPTION � t <br /> Ft to fit ,Describe material grain Stce color etc CITY + � STATE ZIP <br /> _ ¢¢ Address <br /> i_ 'I WELI LlI1, T qN <br /> 7 ' - 3 \_t City �" SS 44CAI _ <br /> County ` L ` <br /> ' ) ` '1 a ` APN Book Page Parcel <br /> I u �� '' ,t kir '' ` ` ` • Townsli Ran Section <br /> 1 ff _ <br /> E,1 � - ORTH ! L� WEST <br /> 1 Latitude- , Longitude I �+ <br /> DEG -VITT` "SEC DEG -M <br /> LOCATION SKETCH ACTIVITI (.::L) <br /> I I ♦_+ r t ti d�� �". ! i"F+ NORTH NEW WELL <br /> I I t L ' ✓ l 1 t,.. , <br /> MODI FlGATIpNIREPAIR <br /> — Deeper- <br /> - <br /> eepen— Other(Specify) <br /> F <br /> I i 4t <br /> DESTROY(Describe <br /> I Procedures and Materials <br /> Under GEOLOGIC LOG l <br /> PLANNED USES <br /> ` WATER SUPPLY <br /> '� C1 Domestic Public <br /> ~` f., Irrigation Industrial <br /> ti F <br /> u MONiTORfNG <br /> TEST WELL <br /> I I 4— J_ CATHODIC PROTECTION— <br /> HEAT EXCHANGE— <br /> DIRECT PUSH <br /> I I <br /> INJECTION <br /> VAPOR EXTRACTION <br /> SPARGING <br /> SOUTH REMEDIATION <br /> S Illustrate or Describe Distance of Wellrant Roads Buildings <br /> Pences Ricers etc and attncle a nuep Use additional aper rf OTHER(SPECIFY) <br /> necessanj PLEASE BE ACCURATE dr GOMPLET <br /> I I l � (•� l,,.i� <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> 1 I <br /> DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft)&DATE MEASURED <br /> I I <br /> ESTIMATED YIELD (GPM)& TEST TYPE_ <br /> TOTAL DEPTH OF BORING �f t (Feet) TEST LENGTH (Hrs) TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not he representative of a well's long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE <br /> HOLE (}TYPEFROM SURFACE TYPE <br /> DIA Y z a MATERIAL f INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) w r a DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MENT TONITE FILL <br /> Ft to Ft g ¢ Ft to Ft TYPEISIZE <br /> In N coo (inches) THICKNESS (]riches) (�) (�) (�) ( ) <br /> w <br /> I <br /> I I <br /> I <br /> I I <br /> ! ! <br /> I I <br /> ATTACHMENTS (zL) CERTIFICATION STATEMENT <br /> l <br /> Geologic Log <br /> I the undersigned certify that this report as complete and accurate to the best of my knowledge and belle[ <br /> — <br /> Well Construction Diagram NAME �Aj, .. k, r ( 'J 1 ; I I ri <br /> (PERSON FIRM OR CORPORATION) (TYPED OR PRINTF i <br /> Geophysical Log(s) ( IL1 <br /> Soil Water Chemical Analyses t it(" i; r . ) T ' <br /> Other �> �-- f rz { ADDRESS CITY STATE 1 ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS2 • <br /> Signed <br /> L DRILLERIMTHORIZED REP E GATE SIGNED C 57 LICENSE NUMBER <br /> i)t51t 1S4 HPC 11 97 IF ADDITIONAL SPACE IS NEEDED USE NEX CONSECUTIVELY NUMBERED FORM <br />