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ORIGINAL STATE OF CALIFORNIA USE NLY — 00 N I <br /> File with DWR WELL COMPLETION REPORT <br /> Page—of. /y Refer to Innnection Paulphlet STATE WELL NOISTATION NO <br /> Owner's Well No t�T(L—�� No. ` )346191r y d ❑ 1 J I ❑ <br /> O=rk Began 2E1 M5 Ended LATITUDE LONGITUDE <br /> PerlTut Agency a <br /> Permit Na [ap Permit Date APNITRSIOTHER <br /> GEOLOGIC LOG WY;LL OWNER <br /> ORIENTATION (jC) ^VERTICAL -HORIZONTAL _ANGLE -(SPECIFY) Naine <br /> DRILnMr1rioo FLUID M g Address O (05 �/ <br /> DEPTH FROM —1570 <br /> suRFACE DESCRIPTION <br /> FL to Fl Describe rngterlal grain size,calor, qtc Cin STATE ZIP <br /> LOCAT N <br /> V i Address a5 <br /> ' IR <br /> City f <br /> County <br /> -- <br /> UA&5 APN Book Page 'l qj 90) <br /> ' Township"T" S Ran a A_Sethon <br /> ' Latitude 1 5)� NORTH Longitude /21 1 ala 08 WEST <br /> I r DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> 1 ' NORTH _.... NEW WELL <br /> L40DIFICATIONIREPAIR <br /> 1 I <br /> Other( <br /> Other(Specify) <br /> DESTROY(Describe <br /> Pmvepvros&w Marortals <br /> V ► Under"GEOLOGIC LOG) <br /> I 1 PLANNED USES (4) <br /> t WATER SUPPLY <br /> 1 1 <br /> Domestic _ Public <br /> trngelion — Industrial <br /> 1 I ' MONITORING <br /> TEST WELL <br /> I I CATHODIC PROTECTION <br /> i HEAT EXCHANGE <br /> 1 I <br /> DIRECT PUSH <br /> ' 1 INJECTION <br /> VAPOR EXTRACTION <br /> t ' SPARGtNG <br /> 1 1 SOUTH REMEDIAT[ON_ <br /> Ilhulrate or D escriha DMeance of Writ(nine&x7ils Butlrllll;;r <br /> 1 1 Fencer Reura etc mid attach a Meruu Use aelrl,r(oael 1rrtjaer!f OTHER(SPEC(FY) <br /> necetsart� PLEASE BE ACCVRAI'E&COMPLETE <br /> 1 1 <br /> 1 1 <br /> WATER LEVEL dr YIELD OF COMPLETED WELL <br /> t , DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (FI)&DATE MEASURED <br /> I r <br /> ESTIMATED YIELD (GPM)d TEST TYPE.. <br /> TOTAL DEPTH OF BORING Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (FI) <br /> TOTAL DEPTH OF COMPLE'T'ED WELL -----(Feet) 'May not be rrptwentattve of a wells long-term yield <br /> CASING (S) ANNULAR MATERIAL <br /> FROM S <br /> DEPTH <br /> HDLE TYPE(4) FROM SU FACE <br /> TYPE <br /> DIAMATERIAL! INTERNAL GAUGE SLOT SIZECE gpy <br /> Ft to (inches) $ a <br /> GRADE DIAMETER OR WALL IF ANY MENT NME FILL FILTER PACK <br /> (InMea) THICKNESS (Irich-) Ft to FL (TYPEIStZE) <br /> (�) (`:) (`c) <br /> e t <br /> I , <br /> 1 <br /> t � <br /> I � <br /> ATTACHMENTS (z�.) CERTIFICATION STATEMENT <br /> _,_. Geologic Log I,the unjersigned,Certify tthCaattthis report Is complete and accurate to the best of my knowledge and belief <br /> _ well Construction Diagram All Q�a� a�j*-' L L <br /> Geophysical Log(s) {PEI WK FIRM. OR CONFORAT19M (TYPED OR PRINTED) If <br /> SoLWater Chemlcni nalyses V <br /> A/Other DRESS CrrY STATE Zip <br /> ATTACK!ADAlTlDNAL INFpRMATIC IF lT EXl3T81113 - ( I �6;t WELL DRIlLER/AU [2E11 4��- <br /> rA SICNE C 57 LICENSE Rt1M ER <br /> D'a'n 188 REV 11 91 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />