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�4 <br /> ORIGINAL STATE OF CALIFORNIA RWR Yq§ ONLY — 00 NQT Flt <br /> File with DWR WELL COMPLETION REPORT <br /> Page !(Of.3 lf Ile ar to Instructfan Pamphlet STATE WELL NOJSTATION NO <br /> Owner's Well ��J No "W i-k,� ' ❑Ej ❑ <br /> No 6Q3 LLA�, <br /> e Work Began l , Ended II rad?aQ05 t� 1,s ; , _ LATITUDE LONGITUDE <br /> qllW-ocalPernvt Agency vte ri i r <br /> Pen-nit No �k"23'2S APNITR$fOTHER <br /> Permit Date <br /> � ;EOLOCIC LOG WELL OWNER <br /> ORIENTATION (_T) VERTICAL _HMMONTAL —ANGLE —(SPECIFY) Nam <br /> DEPTH FROM <br /> MRETHOD FLUID Mai g Address <br /> SURFACE DESCRIPTION !:agA • 5 Q <br /> Ft W R. Describe material grain size, Color 4tc CITY STATE ZIP <br /> a r LOCATIO <br /> Address ,! <br /> Clty <br /> County n o� <br /> ' APN Book Page arael a <br /> TownshipM!a? Ran a 1�5 Section <br /> 1 'AI 31 v Latitude a-7 ,qj:;. 114aNORTH Longitude jai (0 1 96 -EST <br /> DEG MIN SEC DEG MIN SEC <br /> LOCATION SKETCH ACTIVITY (,) <br /> r NORTH NEW WELL <br /> 1 MODIFtCATIOWREPAIR <br /> I t _ Deepen <br /> I I �.. Other(SPrcity) i <br /> e <br /> r , <br /> DESTROY(DescribeProcaMaid <br /> Under <br /> and Af LOG i, <br /> Undar YiEOLOGlC LOG) <br /> PLANNED USES (zn) <br /> i 1 WATER SUPPLY <br /> Domestic _ P011c <br /> 1 <br /> h — IrrlpsUon Industrltl <br /> MOMTORiNO <br /> TEST WELL <br /> 1 1 CATHODIC PROTECTION <br /> 1 1 <br /> HEAT EXCHANGE <br /> \ r r DIRECT PUSH_ <br /> INJECTION <br /> I I VAPOR EXTRACTION <br /> r SPARGING <br /> 1 , SUTH REMEDIATION_ <br /> lumemte or Urzcnhc Distance of Iveli fn,w Ala& BuIldings <br /> Fences PdLers ere and attach a in Use <br /> ndrhtfunal 7xrNrr 1f OTHER{SPECIFY)...... <br /> aecesurnl PLEASE HE ACCURATE C*COMPLETE <br /> I 1 <br /> � 1 <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> r i DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> 1 DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> r ESTIMATED YIELD' (GPM)A TEST TYP <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs)TOTAL DRAWDOWN (n) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be 5pruentative of a toellrs long-term yield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> SURFACE <br /> BORE- <br /> FROM TYPE(4) <br /> FROM SURFACE TYPE <br /> DIA }�' MATERIAL/ INTERNAL GAUGE: SLOT SIZE CE- I BET. <br /> (InerMn) ir GRADE DIAMETER OR WALL IF ANY MENT TOWT FILL FILTER PACK <br /> ITT to Ft. (In&,=) THICKNESS (Inches) F1 to PL (TYPEZIZE) <br /> (✓) 00 (✓} <br /> 1 , <br /> i <br /> t , <br /> 1 <br /> I 1 <br /> i <br /> r I <br /> ATTACHMENTS (x!) CERTIFICATION STATEMENT <br /> ____ Geologic Log 1,the undersigned certify that this report Is Complete and accurate to the beat of my knowledge and belief <br /> —Well Construction Diagram NAME OLjL MCr ac <br /> — Geophysical Log(s) (PERSON. fIRM.OR CORPORATION) (TYPED OR PRINTED) <br /> SOIWVater Ci)0MIca1fr9alyeea Q �� � � �• t � V� T>a C}'� ��`4�� <br /> �oa,et Sr '�. dy woREss � s crrY STATE ZIP <br /> ATTACH nODfrrarrAl f1VFOgMrtl77ofY IF Jr 1"xrsrs s ` . �4! _ I � ` �� <br /> WELL ORILLER1Al1THf1R ED REPRESENTATIVE DAT SIGNED C-57 UCENSE NUMBER <br /> OWR INN REV 11 97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />