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ORIGINAL STATE OF CALIFORNIA __owo USE ONLY - 00 NOT FILL <br /> Pile with DWR WELL COMPLETION REPORT <br /> Page—of Refer to )nstrucrion Pantphler STATE WELL NO/STATION NO <br /> Owner's Well No 6- 1 No I41L ` ' ' 111 d, � '� ❑ ❑ <br /> to Work Began t aqp r> , Ended 1( O LATITUDE LONGITUDE <br /> Local Permit Agency Suet tvt ` <br /> Permit No 2"3S Permit Date /0 (, APNITRSlOTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION {2} VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> 1ADi 0, <br /> DRILLING <br /> DEPTH FROM METHOD FLUID M ng AhdreS SOS <br /> SURFACE DESCRIPTION A r <br /> Ft to FL Describe material, grain size, calor, etc 01 r STATE ZIP O <br /> 1 1 Addres 3 a WELL CATION ✓ <br /> Z City <br /> I , <br /> County LISrL <br /> + 1 APN Book Page arcel 171!4(RdaC7 <br /> 1 41 3/ Townshi <br /> 1 p �R�an/ge Septan <br /> Latitude 3- S I`T;aNORTH Longitude G NON SEC DEGI a4 SEC <br /> LOCATION SKETCH ACTIVITY (�) <br /> 1 NORTH <br /> �.� NEW WELL <br /> I I <br /> MODIFICATIOWREPAIR <br /> /A"6" — Deopm <br /> + — Other(SPedfy) <br /> r + <br /> = oESTAOY(ba✓<eNb1 <br /> I + Proerdvroa and Alalsnelo <br /> Under VEOLOOIC LOQ J <br /> I F <br /> PLANNED USES { ) <br /> WATER SUPPLY <br /> + + Dametlla w Public <br /> lirigalloI Induetnel <br /> 1 1 MONITOFTIIJ13 <br /> I I TEST WELL <br /> I I CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> + + DLAECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> i r <br /> SPARGING <br /> 1 SOU111-i REMEDIATION <br /> 171nsrmre Or Urvcrlhe Distance of Well rrtnn Anndr a,rllrll,t � <br /> 1 I Fences Alter etc pied allnch a utap1 Use addltrg1�Ere)+er i OTHER(SPECIFY) <br /> necatary PLEASE BE ACCURATE&CO., <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> + I DEPTH TO FIRST WATER (FL)BELOW SURFACE <br /> + I DEPTH OF STATIC <br /> t r WATER LEVEL (FT)&DATE MEASURED <br /> ESTIMATED YIELD (GPM)d TEST TYP <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN,.,__(Ft) <br /> TOTAL DEPTH 4F COMPLETED WELL (Feet) •May not be rpresentflUVe of a melrt long-tern yreld <br /> DEPTH CASING (S) <br /> FROM SURFACE HORS- rypE DEPTH ANNULAR MATERIAL <br /> FROM SURFACE TYPE <br /> DIA. MATERIAL I INTERNAL GAUGE SLOT SIZE <br /> Ft, to FL (Inch-) GRADE DIAMETER OR WALL IF ANY ENT oll FILL <br /> FILTER PACK <br /> {Indrea) THICKNESS (hmlwq Ft to FL (n) (:) (2i) (TypesIZE) <br /> + <br /> I � <br /> I <br /> I I <br /> + + <br /> 1 ATTACHMENTS (4) CERTIFICATION STATEMENT <br /> Geologic Log I,the and rstgned,Certify that this report 8 Complete and accurate to the best of my knowledgeandbellef <br /> Well Construction Diagram <br /> Geophysical Log(e) (PERSON, FIRM DRG PDRATION) ITIPED OR PRINTED) <br /> - /Som etoemits! tirses <br /> r✓Other <br /> -&T,= ADDRESS <br /> CRY STATE Zip <br /> r <br /> ATTACH AD0177ONAL A'VFoRNG4TIOAL 1F!T EXISTS ' <br /> WELL UHIUER/AUTYMED REPRESENTATIVE DATE SIGNED C 57 LICENSE NUMBER <br /> DIVA IM REV 1)-97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />