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ORIGINAL STATE OF CALIFORNIA DWO USK ONLY — DO 140T FILN <br /> File with DWR WELL COMPLETION REPORT <br /> Page/Of Refer to Instruction Pamphlet STATE WELL NOISTATION NO <br /> Owners Welt No No IS03453,1—i k- ry"F ❑ ❑ <br /> 0te Work Begart , Ended db;-o ��� LATITUDE LONGITUDE <br /> Local Permit Agency <br /> Permit No o0 4 a Permit Date APNITRSIOTHER <br /> � GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (�) L/yE ql —HORIZONTAL —ANGLE —(SPECIFY) Name t � <br /> u <br /> DRILLING <br /> DEPTH FROM METHOD FLUID MAnig Address O' o 5 <br /> SURFACE DESCRIPTION [f5 <br /> 70 <br /> Ft to R Describe material, grain size color, etc Cm STATE ZIP <br /> 0 r I r Address o7 W LOCATIO <br /> City-:11�lq _ <br /> ' County �"s-m►'I 'ry_Q_tcctr✓� _ <br /> ' y APN BOOk�Page Parcel 521L0 <br /> ` Township 1 et J R ge G Section 4 <br /> I I Latitude o Iq5 T -NORTH Jongitude a G sEcWEST <br /> D <br /> LOCATION SKETCH ACTIVITY (=) <br /> 92 <br /> NORTH <br /> NEW WELL <br /> t I <br /> MODIFICATIONMEPAM <br /> Ek — Deepen <br /> I I � Other(Specify) <br /> r + — DESTROY(Dewdbr <br /> I I Prdeedur"Md Matartatr <br /> Undol"GEOLOGIC L06 J <br /> I I <br /> PLANNED USES (�} <br /> I , <br /> WATER SUPPLY <br /> Dumr91IC — Public IrngtllonInduatrigl <br /> I t Lj <br /> I � YQI MONITORiNO.,, <br /> TEST WELL <br /> I I CATHODIC PROTECTION <br /> r r HEAT EXCHANGE <br /> � I 1 <br /> DIRECT PUSH <br /> I t INJECTION <br /> VAPOR EXTRACTION <br /> SPARGU40 <br /> r r SOUTH REMEDIATION <br /> Illudarte or Dewcrllx Dlwance of Wrli famr Remelt Pntldhlm <br /> r r Fences Rll,ers etc and attach a ninjo Use additional yea wr!v OTHER(SPECIFY) <br /> necessary PLEASE HE ACCURATE 0 COMPLETE <br /> i I <br /> I I <br /> WATER LEVET. Er YIELD OF COMPLETED WELL <br /> I r DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> I I DEPTH OF STATIC <br /> WATER LEVEL (Ft)G DATE MEASURED <br /> ESTIMATED YIELD (GPM)6 TEST TYP <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAwDOWW (Ft I <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) "M trot be reprerenwtrue of a well's Am -terns yield <br /> DEPT( BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE —' FROM SURFACE <br /> TYPE <br /> DIA MATERIAL INTERNAL GAUGE SLOT SIZE <br /> (Inches) E - <br /> � to FLGRADS DIAMETER C <br /> OR WALL !F ANY MENT TONI8ENTE FILL FILTER PACK <br /> (In&") THICKNESS (Inchn) Ft to Ft (�) (�) (—) (TYPE/SIZE) <br /> I I <br /> I <br /> I I <br /> I I <br /> r I <br /> r � <br /> ATTACHMENTS (z�) CERTIFICATION STATEMENT <br /> _ Geologic Log 1,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> Well Constnxftn Diagram X'ME W 00 W 0 r LGA A/G- do A . <br /> _ Geophysical Log($) !PERSON FIRM OR CORPORATIOnj UTPEO OR PRINTED) <br /> Som ,chartsIy o c v R a � 0 U/S <br /> �oiher ADDRESS CITYa STATE ZIP <br /> ATTACH ADAITXNML tNFORMWTlON, IF✓?EXISTS <br /> WELL UNILLERIAUTHOJUED REPRESENTATIVE DA7 SIGN C-57 tJCFNSE_NtJMBER <br /> DWR 188 REV 11A7 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />