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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — o FI IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page 1 Of ✓ / "r to Irrstnlctlon Pamphlet STATE WELL NOISTAYLO14 NO <br /> Owner's Well No ""3L1 a No 10(} 4525 � :Ylf ''ti 1i <br /> tt__ -- �� I LATITUDE LONGITUDE <br /> cZa3I <br /> *te Work Began �..a , Ended.. id I <br /> Lova!Pennrt Ag/e1n�c�y C a <br /> Permit No —ODA4A — APN7TRSlOTHER <br /> Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> 0 An <br /> ORIENTATION (4) =VERTICAL _HORIZONTAL ANGLE _(SPECIFY) Name <br /> DRILLING <br /> DEPTH PEW— METHOD FLUID M g Address o X S <br /> SURFACE DESCRIPTION & 57� <br /> Fl. to FL Discribe material,grain size, color, etc CRY STATE ZIP <br /> AE LOCATION <br /> ddress 3 <br /> ' , L v►k N--- e0w City c <br /> County S4A tact ew LA e!'1.� <br /> LV 3, APN Book Page Parcel a 3� <br /> Y. Township an S Re �S <br /> Latitude 31 ,SFS_(gC NorrrH Longitude J RJ I PL& IR WEST <br /> r DEG MIN SEC DEQ MIN SEC <br /> LOCATION SKETCH ACTIVITY (,) <br /> t NORTH NEW WELL <br /> MODIFICATIONIREPAIR <br /> ! , CA — Deepen <br /> i — Other($pecity) <br /> F E$TROY(Describe <br /> I I <br /> Pmcedurra and Materials <br /> Under"GEOLOGIC LOG 1 <br /> PLANNED USES (.4) <br /> I I WATER SUPPLY <br /> Deennflc Public <br /> F Itrigateon ,,, Industrial <br /> a r <br /> MONITORING <br /> e TEST WELL ,.. <br /> ! , CATHODIC PROTECTION_ <br /> r HFAT EYCHANGE <br /> DIRECT PUSH <br /> � I ! <br /> INJECTION <br /> r VAPOR E)ITRACTION_ <br /> i 1 SPARGING_ <br /> I I SOUTH REMEDIATION <br /> 111rrdrMe or Devcrilx DLsrrrace of SVrR frrwr RaadA 9111NIJIgS <br /> r r Fences Rlwn etc and attadi a crap uar addlfiutrai icr if OTHER(SPECIFY)_..._ <br /> nrmsanf PLEASE BE ACCURATE&COMPLETE <br /> I r WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I DEPTH TO FIRST WATER (FI) BELOW SURFACE <br /> DEPTH OF STATIC <br /> I I WATER LEVEL (PI)d DATE MEASURED <br /> I <br /> e ESTIMATED YIELD (GPM)d TEST TYPE <br /> TOTAL DEPTH OF BORING Feet} TEST LENGTH (Hro)TOTAL DRAWDOWN (Ft) <br /> TOTAL, DEPTH OF COMPLETED WELL (Feet) *May not be nip enwttve of a well'r long-alai yield <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE = FROM SURFACE TYPE <br /> DIA MATERIAL/ INTERNAL GAUGE SLOT SIZE CEBEN <br /> R (inches) pgppE DIAMETER OR WALL IF ANY MINT ONI FILL FILTER PACK <br /> m (Inam) THICKNESS peechaa) FL to FIL } (✓} {T} (TYPE/SIZE) <br /> I <br /> I , <br /> I <br /> I r <br /> I , <br /> i ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> Geologic Log 1,the undersigned,certify that this report is complete and acDurate to the best of my knowledge and belief <br /> Well Construcbon Diagram AtAMF e, G <br /> Oeophyslpl Logs) <br /> (PERSON, FIRK UR CDR TION) (TYPED OR PRINTED) <br /> � 1�11slys <br /> 7olllVltater Ch etysee ' <br /> Other ADDRESS CITY $TATE ZIP <br /> ATTACH ADDITIONAL INFORMATION IF IT EXISTS S'9^ s�3 OQ <br /> WELL OR1tLER! 12E0 REPRESENTATIVE DAT SIGNE9 C 57 LICENSE NUMBER <br /> L)WR bite REV 114;7 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />