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ORIGINAL <br /> File with DWR STATE OF CALIFORNIA R ONLY _ 00 NOT F11 , <br /> WELL COMPLETION REPORT <br /> Page---of, Arfdr to Instruction PdruNhLt STATE WELL NOISTATION NO <br /> Owner's Well No d �� No. e034S20 `5 ❑ <br /> ry�``r ", ❑ <br /> ate Work Began a 7 0 J<— , Ended I A �S � . <br /> LATITUpE LONGITUDE <br /> qW Local Permit Agency <br /> Permit No Permit Date �� APN/TRS/OTNER <br /> GEOLOGIC LOC <br /> ORIENTATIONWELL OWNER <br /> {—} �VEATX:AL —HORIZONTAL _ANGLE (SPEGFI) Name <br /> DRILLING <br /> DEPTH FROM METHOD FLUID ling Address <br /> SURFACE DESCRIPTION Q�S 7d <br /> PL to FI Describe material grain size, color, etc CRY STATE ZIP <br /> W LL LOC I N <br /> r <br /> Address <br /> I ti r City <br /> ` County <br /> 1114 C APN Book Page Parol <br /> ' I l <br /> ' g Township'La 55 Range,256- Section ! <br /> 1. Latitude o pS I t"';a NORTN LongitudewEsr <br /> + 1WN A <br /> LOCATION SKETCH DEG <br /> GACTIVITY SEC <br /> �) <br /> ' I r NORTH NEW WELL <br /> + I I MOQIFICATImpeEPAIR, <br /> Dampen <br /> Other(Speafi,) <br /> 1 1J24 DESTROY(prrenba <br /> Procedurrs and Marrnrls <br /> 1 Under GEOLOGIC LOO-1 <br /> + I PLANNED USES (�} <br /> WATER SUPPLY <br /> 1 ' Domev,* _ Pub,,o <br /> I <br /> Irriyallon — induslnal <br /> + 1 MONITORING <br /> I , TEST WELL <br /> CATHODIC PROTECTION <br /> 1 , <br /> HEAT EXCHANGE <br /> DIRECT PUSH <br /> ' + INJECTION <br /> 1 , VAPOR EXTRACTION <br /> r <br /> SOUTH SPAAGWG lllirxfmte or Ulrvcrllrc plvtrtrrcr of tVrl1 frrnu Arx+rls Arrdrlfa},rx REMEDIATION <br /> Fences Rirerw etc and aHdch a rrla 1 use addltlund( lrr♦irr IOTHER(SPECIFY) <br /> rwawnj PLEASE BE ACCURATE&COMPLET <br /> ' + WATER LEVEL & YIELD OF COMPLETED WELL <br /> ' + DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> ' + DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> TOTAL DEPTH OF BORINGESTIMATED YIELD (GPM)8 TEST TYPE— <br /> �'(F2Ct) TEST LENGTH (Mrs)TOTAL DRAWDOWNL _(Ft) <br /> TOTAL DEPTH OF COMPLETED WELL {Feet) 'M b <br /> ay not repramtatMe of a WeLpi ion -term yield <br /> CASING (S) <br /> FROM <br /> DEPTH <br /> RACE HOLE TYPE ,,) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE TYPE <br /> DIA, MATERIAL I INTERNAL GAUGE SLAT SIZE <br /> Ft to FL (rnwne) f GRADE DIAMETER OR WALL IF ANY CE BEN FILTER PACK <br /> bS finches) THICKNESS pnehn} fry MEAT TONfTE FILL <br /> 1 <br /> 1 ' <br /> 1 ' <br /> I ' <br /> I <br /> 1 <br /> ATTACHMENTS (,) CERTIFICATION STATEMENT <br /> _ Geologic Lop I,the undersigned,Certify that this report Is complete and accurate to the best of my knowledge and belief <br /> — wen Canstnrctlim Diagram NAME �� LL C— TAIC . <br /> -- Geophyalca)Logs) (PERSON FIRM,OR CORPORATION) D OR PRIMED) <br /> Soll/Water chamlcal lyase d IRul5k. � R /f <br /> *"Other ` ADDRESS l� <br /> CITY STATE ZIP <br /> ATTACH ADDITIONAL IN<OfiAsa77o7Y <br /> IF IT Exrsrs 'pod • Z O <br /> 1NELL ORILLERIAUTN EO REPRESEMATIYE pA SIGNFDC-7 LICENSE NLIM6 f <br /> llWR 188 REV I1J IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FOAM = <br /> L <br /> i <br />