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ORIGINAL STATE OF CALIFORNIA DWR USg ON Y — PQ NOT FILLIN <br /> File with DWR WELL COMPLETION REPORT <br /> Page!Of-,3 ,y / Refer to fairtntction Pamphlet STATE WELL NOISTATION NO <br /> Owners Well No y�s`�`a��c�• No. 4B©3�52$��` ''�"� ,��� ❑ ❑ <br /> Work Began Ended O t <br /> s ITr LATITUDE LONGITUDEocal <br /> Pen-nit A,gencyds w <br /> Permit NoAPNrrRSIOTHER <br /> PerTnit Date D � <br /> GEOLOGIC LOG WELL OWNER ��rl <br /> ORIENTATION (:) VERTICAL _HORIZONTAL ANGLE „_,,.(SPECIFY) Name -- P <br /> MRILLING ETHOD FLUID M g Address �" �iJFJ <br /> DEPTH FROM 70 <br /> SURFACE DESCRIPTION 7 <br /> IR to FL Desenbe material,grain size, color, etc CITY STATE ZIP <br /> i= <br /> E LOCATI <br /> ' �'S' r Address—3LA-Qr5 AJ <br /> t Cit <br /> County '7'rst <br /> I L <br /> nty o ci t <br /> TC 3' 1LL�!a V.04.6te4 APN Book Page Parcel Section !`// - <br /> F Townsh> Ta S R��n gi e <br /> Lahtude 1 I�lyd NOPITH Longitude I;tI ars WEST <br /> I IDEG MLN SEC DEG WN SEC <br /> M LOCATIOON KETCH ACTIVITY (4) <br /> ' _ NEW WELL <br /> ' I; MpOFFICATI AIR <br /> I I 492(:�Ju <br /> Dmapen <br /> aapon <br /> Olhar(SPacitV) <br /> I I 1 DESTROY(Dounba <br /> Procedure*and Miriana0z <br /> Under GEOLOGIC LOG <br /> PLANNED USES (4) <br /> 1 WATER SUPPLY <br /> I I <br /> — Domaatle Publta <br /> Irrigation Industrial <br /> MONITORING— <br /> I t <br /> TEST WELL T, <br /> 1 I CATHODIC PROTECTION <br /> I I <br /> HEAT EXCHANGE <br /> � I 1 <br /> DIRECT PUSH <br /> I i INJECTION <br /> VAPOR EXTRACTION�... <br /> I e <br /> SPARQING <br /> 1 SOUTH REMEDIATION <br /> 11111drate or Ikscrdre Dwtarrm of Well froru Rands 8lellrll)li s <br /> I I Fencer Rivers etc and attnd,a nra r Use additional xglCr OTHER(SPEGFY) <br /> nemsary PLEASE BE ACCURATE it CDMBLET <br /> 1 I <br /> I 1 <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> 1 I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> 1 1 DEPTH OF STATIC <br /> WATER LEVEL (Pt)&DATE MEASURED <br /> r 1 <br /> ESTIMATED YIELD (GPM)a TEST TYA�- <br /> TOTAL DEPTH OF BORING (Feet) <br /> TEST LENGTH (Mm)TOTAL DRAWDOWN (Ft) <br /> TOTAL DEP'T'H OF COMPLETED WELL Feet) •May not Le representatrur o a well's long-terfn told <br /> DEPTH BORE- <br /> HOLE <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE(_) FROM SURFACE TYPE <br /> DIA MATERIAL I INTERNAL GAUGE SLOT SIS CE 8EW <br /> (EtCI+as) GRADE DIAMETER OR WALL IF ANY MENT EW <br /> BE FILL FILTER PACK <br /> Ft to FL (InChaa) THICKNESS pntllaa) FL to FL <br /> (�} (_) (TYPESIZE) <br /> 1 <br /> I <br /> I <br /> L <br /> 1 <br /> ATTACHMENTS (,) CERTIFICATION STATEMENT <br /> r Geolop(C Lop t,the undersigned.Certify that this report is complete and accurate to the beat of my knowledge and belief <br /> Well Consvucuon Diagram NAME Ae/LLI oiz— /VC <br /> (PERSON, FIRM, OR CORPORATIOM (TYPED OR PRINTED) <br /> Geophy8lcai Log(s) a woe R o . 7 <br /> Solmater IrAI " EE <br /> '/motor V ADDRESS Cm STATE ZIP <br /> ATTACH ADDITIONAL INFOAM4Titl , Il=IT EXISTS sign * 1 +Z3 I b r. 71 100 <br /> WELL DRrLLELA ORIZED REPRESENTATIVE rE SIGNE C S7 LICENSE NOM EA <br /> DWR tell! REV 11-®4 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />