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r <br /> ORIGINAL STATE OF CALIFORNIA 2WI3 USE ONLY – pQ NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page !!sof-,?— / r r Rrfer to Instruction Paluyhlet STATE WELL NO/STATION NO <br /> OWt:ler'S Weil �I�5 `apt'ra74 ND. ,r+�..�.- R- _f e <br /> IYD e�13 '524, ; elf <br /> to Work $egan a Q � , Ended LATITUDE LONGITUDE <br /> Permit Agency �L:1 n � iY <br /> Permit No Obi 4�a5 _PermTt Date O a� APNlrRS/OTHER <br /> / GEOLOGIC LOG WELL O "N�E <br /> ORIENTATION (✓) V.RTICAL —HORIZONTAL —ANGLE (SPECIFY) Name 1 r <br /> DRILLING M Address g <br /> DEPTH FROM METHOD FLUID gi <br /> SURFACE DESCRIPTION �7 0 <br /> Ft to FL Describe material grain size, calor, etc CITY STATE ZIP <br /> t WELL LOCATI <br /> Address <br /> 4522 city <br /> County say, u I r L- <br /> ' G APN Book Page Parcel a� <br /> a• <br /> ' Township=_6L_Ran e 5 SeLfion KIP <br /> I IcAviat Ap Latitude 37 1445 I NORTH Longitude 198 WEST <br /> i DEG MIN $EC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (_) <br /> I I NORTH <br /> NEW WELL <br /> 1 I <br /> MODIFICATION/REPAIR <br /> Olherf <br /> Other{SPetafy} <br /> t I <br /> DESTROY(Descnbe <br /> Pmeedurve and Materiels <br /> Under <br /> UnrMr GEOLOGIC LOG) <br /> PLANNED USES () <br /> I I WATER SUPPLY <br /> Domestic PutaK <br /> IrDA ion IndustrIMI <br /> MONITORING <br /> TEST WELL <br /> I i CATHODIC PROTECTION <br /> I i <br /> HEAT EXCHANGE <br /> DIRECT PUSH— <br /> t I <br /> Ie-uEcnoN...... <br /> VAPOR EXTRACTION <br /> I I SPARGING <br /> ` I SOUTH REMEDIATION_ <br /> Ilhatrate ar Lkwribe LWarrcr of lVell freed RIMA Bnilding-v <br /> I 1 Fences Ell— etr and atMch a Imp Use odrhtional rqvrff OTHER(SPECIFY) <br /> necessdrtf PLEASE BE ACCVAATE G COMPLET <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> � I <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> { t DEPTH OF STATIC <br /> WATER LEVEL (FL)6 DATE MEASURED <br /> ESTIMATED YIELD' (GPM)& TEST TYPE ,.. <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hua)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a weUrt loo -trim zold <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE(—' FROM SURFACE TYPE <br /> DIA <br /> MATERIAL 1 INTERNAL GAUGE SLOT SIZE CE BEN <br /> (Inches) GRADE DIAMETER OR WALL IF ANY MEM TONITE FILL FILTER PACK <br /> FL to FL Unchas) THICKNESS (Irrchoa) Ft to FL (�) (`) (TYPEISIZE) <br /> I r <br /> i <br /> I 1 <br /> 1 <br /> 11 <br /> 1 t <br /> ' ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> — Geologic I,the undersigned, cer*that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram MME <br /> IPERSO M OR CO PD ON) (TYPED OR PR! I <br /> S0IhWysicel Log(s) � i u 0 Q ws w _ djSCA <br /> - ��SoD/VJlatgr Ce lea Lyses 1 <br /> y& i AOORESS CITY STATE ZIP <br /> t <br /> ATTACH ADDITIONAL INFORMATION iF Ir Exists LL ORILLER/ ORIZED REPR SENTATIYE , E SIGNE LICENSE A 'UM' R <br /> DWR 188 REV It 97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />