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t <br /> rr� <br />• ORIGINAL. STATE OF CALIFORNIA ON Y — 120 N N <br /> File with DWR WELL COMPLETION REPORT <br /> Page Of,_ `/ Refer to Instruction Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No.Job—? C.�e� No. <br /> e034 341; , '`',r;Y k ❑ ❑ <br /> Wcal <br /> Work Began a�5 Ended LATITUDE LONGITUDE <br /> Pennit Agency APN/TR$lOTHER <br /> Permit No =tD Permit Date <br /> GEOLOGIC LOG WFILL OWNER p <br /> ORIENTATION (�) VVERTtCAL —HORIZONTAL —ANGLE _(SPECIFIC) Natne u I <br /> DEPTH FROM <br /> MRETHOD FLUID M ng Address <br /> SURFACE DESCRIPTION 5 7 d <br /> FI W FL Dt.scribe material, grain size, color, etc CITY <br /> 0 ' 7• ' Address e E OCATION <br /> s Ir,I 1 <br /> City <br /> County m4 �r oZ chi <br /> APN Book.�- Page sacci <br /> Township Ranre.�Section <br /> 1 y Latrtude 3� �oRTH Longitude_J;2!--2 wesr <br /> DEO. MIN SEC DEG MINS SEC <br /> i II. �SInd <br /> LOCATION SKETCH ACTIVITY (,) <br /> NORTH NEW WELL <br /> W <br /> MODIFIGATIONlREPgIA <br /> I I — Deepen <br /> _ Other(Specify) <br /> r I f <br /> .._.. DESTROY Posclibe <br /> Pif <br /> rocyduroa arra MrfvAals <br /> Undor'GEOLOGIC LOQ J <br /> PLANNED USES (2�) <br /> i I WATER SUPPLY <br /> 1 r Domeelw Public <br /> Irrigation tndustnat <br /> MONITORING <br /> I I TEST WELL <br /> 1 I CATHODIC PROTECTION ..� <br /> HEAT EXCHANGE— <br /> 1 I DIRECT PUSH <br /> I I INJECTION <br /> I I VAPOR EXTRACTION <br /> l I <br /> SPAROING <br /> SOUTH <br /> ' ' R1edmte or tkscrllx D&tante of WeUlnun R<xrdx 8+111t11u);a REMEDIATION <br /> 1 r Fences Ritcrra rte and attach a ina111 Use additional3rWr!f OTHER(SPECIFY) <br /> rreceslarrf PLEASE BE ACCURATE&COMPLETE <br /> i WATER LEVEL A YIELD OF COMPLETED WELL <br /> I 1 <br /> 1 I DEPTH TO FIRST WATER (Ft) BELOW SURFACE <br /> 1 1 <br /> DEPTH OF STATIC <br /> WATER LEVEL (FL)&DATE MEASURED <br /> 1 k <br /> ESTIMATED YIELD (GPM)& TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet} TEST LENGTH <br /> (Hre)TOTAL DRAWDOWN TO <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) •May not be repruentativie of a well's long-term ield <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE VTYPE(z� FROM SURFACE TYPE <br /> DIA MATERIAL I INTERNAL GAUGE SLOT SIZE CE BENFL ro Fl GRADE DfAMa TER OA WALL !F ANY MENT ITE FILLFIL7EA PACK <br /> (Inches) THICKNESS (IrtdNs) Fl to Ft (�) (�} (� (fYPEISIZE) <br /> 1 � <br /> 1 <br /> I 1 <br /> i I <br /> i I <br /> 1 I <br /> ATTACHMENTS (7�) CERTIFICATION STATEMENT <br /> — Geologic Loy I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> — Well Construction Diagram NAME 'W/Le_/wdC' C N� <br /> WEMN RRK OR CORPORATION) MKO OR PRINT"' <br /> — Geophyslcat Log(s) !'ice 9 7] <br /> /$cWWater Co)gmi "as ESO R D 'kid U I S 707— <br /> ys <br /> Other SI FCL ADDRESS C" STATE IIP <br /> ATTACH A00I770NAL 1NF0RMA710 1F 1T EXISTSf 7 a <br /> Sgnad Wf11 OR111ER/A RILED AEPRESENTAnVE DATI SIGNED C-57 LICENSE NUMUEA <br /> DWR 1811 REV 11a; IF ADDITIONAL SPACE IS NEEDED, USE NEM CONSECUTIVELY NUMBERED FORM <br />