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+ ORIGINAL STATE OF CALIFORNIA -D.VR USE ONLY — F <br /> JLL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page!of 3 Refer to llrstnictlon Pamphlet STATE WELL NO/STATION NO <br /> Owner's Well No 1i�J ~ �lo��- No g(j45 $ '�:- F <br /> Weal <br /> Work Began ti Ended 1! LATITUDE LONGITUDE <br /> Permit Agency n <br /> Permit No a Permit Date /0 A0 ao0 APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (=} VERTICAL —HORIZONTAL _ANGLE �_(SPEGFY) Name ) <br /> DRILLING <br /> DEPTH FROM METHOD FLUID }hng Address 5 <br /> SURFACE DESCRIPTION (f4 <br /> Ft to FL Describe materia{ grain size, color, etc CITY STATE ZIP <br /> 1 , WE LOCATTQ <br /> 1 1 Address aZ r <br /> 1 C,lty <br /> County Isaoa <br /> 1 APN Book Page Parcel all /8652 <br /> TownshipRa I e�SCohon 10 <br /> La itude�t L__ NORTH Loongttude /621-1 " OF WEST <br /> t\. A PtADEG MIN SEC ppG MIN SEC <br /> r , <br /> LOCATION SKETCH ACTIVITY {4} <br /> NORTH NEW WELL <br /> ' f <br /> 1 , <br /> MODIFICATION/REPAIR <br /> oaapan <br /> 1 a — Other(Specify) <br /> 1 r rDESTROY(Doscrlba <br /> 1 Procedures and Atatedals <br /> Undo GEOLOGIC LOG-) <br /> t PLANNED USES { ) <br /> 1 WATER SUPPLY <br /> 1 _,,,, Domestic — Puplic <br /> ^. Irrigation — Industrial <br /> MONITORING <br /> 1 , TEST WELL <br /> CATHODIC PROTECTION, <br /> HEAT EXCHANGE <br /> 1 1 DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> r 1 <br /> 5PARGING <br /> 1l1 <br /> r I rt (f,,. rrrtc tip llexxr!!x DlWence ucr ref LVtlf fnrnr&,nrlx 8lrllrllny„r REMEDIATION <br /> t 1 Fences Biwa etc and atfat.1l a r1IRJJ7 Use additional�xe�er tf OTHER(SPECIFY) <br /> r , <br /> necessarrl PLEASE BEACCURATE&COMPLETE <br /> WATER LEVEL h YIELD OF COMPLETED WELL <br /> t , DEPTH TO FIRST WATER (FL)BELOW SURFACE <br /> t , DEPTH OF STATIC <br /> WATER LEVEL (Ft)S DATE MEASURED <br /> ESTIMATED YIELD (GPM)S TEST TYPE _ _ <br /> TOTAL DEPTH OF BORING --�rFeet) TEST LENGTH (Kra)TOTAL DRAWDOWN_(FI) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be ZLmmratsve of a well's kn -tetra yield <br /> DEPTH _ CASING (S) <br /> FROM SURFACE BORE- TYPE( •} DEPTH ANNULAR MATERIAL <br /> DIA FROM SURFACE TYPE <br /> MATERIAL/ INTERNAL GAWE SLOT SRE <br /> Ft to FL IvlrJ+ee) GRADE DIAMETER OR WALL IF ANY MENT TO FILL FILTER PACK <br /> bbbSSS (lncnea) THIGKNESS pncirea) Ft to PL (rYPEISIZE) <br /> I <br /> I <br /> I ` <br /> 1 <br /> , <br /> t <br /> r <br /> 1 <br /> ATTACHMENTS (_) CERTIFICATION STATEMENT <br /> — 0e01091C Log 1,the undersigned,certify that this report Is complete and accurate to the best of my knowledge and belief <br /> Well Construction Diagram NAME 04#49 W"49 At rr <br /> Geophysical Log(s) <br /> (PERSON fIRAL OR CORPDRAIiDN) (TYPED OR PRINTED) <br /> oRMlater Ch ] 'A t b J t$ <br /> ys� G� Y57 <br /> Other ADDRESS CITY STATE ZIP <br /> ATTACK ADDITIONAL fNFORALtTTON IF IT E)(1975 e <br /> 1. 23 6 00 <br /> 44E1i ORIU.ERlAUT lZE6 REPRESENTATIVE DA SIGNE 57 LICENSE NUMBER <br /> DtivR trill Rev TI& IF ADDITIONAL SPACE 1S NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> r <br />