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ORIGINAL STATE OF CALIFORNIA 12WR Use ONLY — DO I NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page_of Refer to l,tstructfan Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well Na S` No IE0457~"s - � °6 <br /> to Work Began 11 , Ended LATITUDE LONGITUDE <br /> al Permit Agency 5Z t� <br /> Permit No �'l_ a�-3 APNlTRSIOTHER <br /> Permit Date 0 <br /> / GEOLOGIC LOG WELL OWNER <br /> ORIENTATION RTICAL HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING •Q 5 <br /> DEPTH FROM METHOD FLUID M Tag Address <br /> SURFACE DESCRIPTION 0 <br /> . 7Q <br /> Ft so FL Describe material grain size calor, etc CIT STATE zip <br /> LOCATIQ <br /> ' r Address <br /> Clty�� <br /> �C County Sqn D <br /> APN Book Page Pam-el Q d <br /> Township TaS R (�Section 140 <br /> C LatitudeI 4 ,Le/ rroRrH Longitude a/oZ 6 wesr <br /> r s t DEG MIN SEC_ DEO MIN SEC <br /> UL <br /> r , <br /> LOCATION SKETCH ACTIVITY (x:.) <br /> NORTH <br /> t , <br /> NEW WELL <br /> MODiFICATIIR <br /> _,,,,_ Deepen <br /> aspen <br /> — Other(Syaeily) <br /> ' _ DESTROY(Desonoe <br /> r r l <br /> Procodusvir and MateMaterialsr <br /> Und <br /> Under"QEOLt7GIC LOQ) <br /> r ' PLANNED USES (4) <br /> WATER SUPPLY <br /> r , <br /> DDRISVIc _____ Public <br /> _.. Irrigation Industrial <br /> I r <br /> MONITORING <br /> TEST WELL <br /> ' CATHODIC PROTECTION <br /> HEAT EXCHANGE_ <br /> I r DIRECT PUSH <br /> t r INJECTION <br /> VAPOR EXTRACTION" <br /> r ' SPARGING <br /> r r SOUTH REMEDIATION <br /> [u,rstrrte ar LIenr0c DLvancr if Wellf(mit Rr„rrls HudrIlmrs <br /> r r <br /> FORM Rivem etc and attach a r„a Me arhlltlanal -. !f OTHER(SPECIFY)==w <br /> SPECIFY)_. <br /> rtecessanf PLEASE BE ACCt1RATE&COMPLETE <br /> r , <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> r I DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> t DEPTH OF STATIC <br /> WATER LEVEL (Ft)8 DATE MEASURED <br /> 1 ESTIMATED YIELD' (GPM)d TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (MM)TOTAL DRAWDOWN_ (Ft) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) I *May not be Z�rrrentxrme a a wtUi long-terrtr teld <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE RE <br /> HOLE TYPFROM SURFACE TYPE <br /> DIA. MATERIAL/ INTERNAL GAUGE SLOT SIZE CETTT(O"." <br /> EN <br /> Fl to Ft ( ') GRADE DIAMETER OR WALL IF ANYFILTER PACK <br /> Ile' <br /> MENNITE FILL <br /> (Inches) THICKNESS (incus) FL to FL (TYPE/st ) <br /> I � <br /> t I <br /> r <br /> , r <br /> I I <br /> r I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Lop I,the undersigned,Ceitlfyr that this report is complete and accurate to the beat Of my knowledge and belief <br /> _ Well Constnuilon Diagram NAAtI (: 030, <br /> — Geophysical t n(e) OV?SDK IDtK DR CORPORATION) (TYPED OR PRINTED) Q �s <br /> SOIVWater Chprrtieat SSa U C) v/s J y // <br /> 5 <br /> �Othgr n ADDRESS �j CRY STATE ZIP <br /> ATTACH ADDITIONAL INFORMA77ON IF IT EKIS?*a. S y r F • 7 e a 7 <br /> VYELL ORUIER1AlnH REPRESENTATIVE TE 5 EO C-57 LICENSE NUMBER <br /> DWR IHS REV !)97 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />