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ORIGINAL STATE OF CALIFORNIAwONLY — DO NQT FILL IN <br /> File with OWR WELL COMPLETION REPORT <br /> Page--Lof,,!—� Refer ro Inrtnicrlon Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No g�'—S Cl e dt� No ,6034 29 m ,; ,l: r'v ❑ ❑ <br /> to Work Began C Ended t( 30 � ,� N LAnruoE LoNGIruDE <br /> PennttAgenty Ja_ ��ti-, � �- <br /> Permit No �t�I,��35 / APNlrR910THER <br /> - ,Permit Date p/�_--ate,_.__,.,..._-- <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (z�) V VERTICAL —HORizoNFAL 4—ANGLE _(wEcim Nar 9P IARK-n <br /> DEPTH FROM <br /> MAEITHOD FLUID M ng Address S <br /> SURFACE DESCRIPTION Q <br /> FL to FL Describe material grain size, color, etc CITY v STATE Zip <br /> ' Address OCATCON ✓ <br /> I< City <br /> I <br /> County dd! <br /> ' APN Book Page arta Zt ag <br /> CL TownSh� �.Ran e <br /> utxw&- `1 Cj Q N� TH I ongin a 105 WEST <br /> -Oq� Longntude L��> 6 <br /> 1 I DEQ MIN SEC DESS MIN SEC <br /> rr 1�lLOCATION SKETCH ACTIVITY (�) <br /> `" am L S r NORTH NEW WELL <br /> MODIFICATIONIREPAIR <br /> I 1 ar'� 13 WCNom/ — 00 Pon <br /> I k �`� — Other(Spealty) <br /> v <br /> a i p� = DESTROY lDescrlbr <br /> ' I u 1—� Undar GEOLOGICres and LOG <br /> OO) <br /> PLANNED USES (z�) <br /> F + WATER SUPPLY <br /> Dam6911C — Publ,C <br /> _ Irrigation Industrial <br /> I 1 � MONITORING_ <br /> TEST WELL <br /> I CATHODIC PROTECTION <br /> HEAT EXCHANGE T, <br /> ` t 1 DIRECT PUSH�.,. <br /> 1 INJECTION <br /> VAPOR EXTRACTION <br /> 1 I <br /> SPARQING <br /> SOUTH REMEDIATION <br /> lllnstmte ur Dewi lbe DWaace(f TYrll 0f111 Rnads.Bullrlhig <br /> i I Fences Blurs etc and rrttndl a nrn USe adrlrrlvnal►xgx�r!f OTHER(SPECIFY►^. <br /> nemsonj PLEASE BE ACCURATE&COMPLETE <br /> 1 1 <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> i I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> i I DEPTH OF STATIC <br /> WATER LEVEL (Ft)6 DATE MEASURED <br /> 1 r ESTIMATED YIELD (GPM)6 TEST TYP>= <br /> TOTAL DEPTH OF BORING (Flet) TEST LENGTH (Kra)TOTAL DRAWDOWN—(Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not beerentatrve of a well's long—tum yrrld <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE r FROM SURFACE TYPE <br /> (DlIA MATERIAL INTERNAL GAUGE SLOT SITE CE BEN <br /> GRADE DIAMETER OR WALL IF ANY MEM TONITE FILL FILTER PACK <br /> Ft to FL (inches) THICKNESS (Indira) FL to Ft (�) (�) (_) (TYPE/StZE) <br /> 1 <br /> 1 I <br /> 1 <br /> r <br /> I � <br /> ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> _ 06010910 Log I.the undersigned,certify that this report IIsi complete and accurate to the best of my knowledge and belief <br /> _ Well Construction Dlliyram NAME ��✓ "146"' GQ. AZ <br /> _ Geophysical Logs) CtPERSON FIRM,OR CORPORAMom (TYPED OR PRWMDI �7 2SOIVWatOr Chemioal Ana"as SJ d u 1 b V u 09 <br /> Other_Sty tY� ADDRESS Lt I�JAi CITY STATE 21P <br /> ATTACH ADDrnOMAL IMFORMAT70TS �DML"LERIAUMAJIZ1k lF IT"ISEb REPAESENTATIVE 0.4 SIGN C-51 uctiIISE kUM8ER <br /> DWR 188 REV 11 0 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />