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ORIGINAL STATE OF CALIFORNIA DAR USE ONLY — DO NOT FILL IN <br /> File with DWR �LL COMPLETION REPOR <br /> Page—Lof/ Refer to Insb'ucli Pe Pn mphlet STATE WELL N0./STATION NO. <br /> Oemer'sWellNo._W— k —(0 No. 709648 �111 <br /> ate Work Began Ended 0 0 LATITUDE LONGITUDE <br /> `Local Pen nit Agency S 5 H — /f <br /> PermitNo. 51t#00339011 Permit Date D APN/TRS/OTHER <br /> EOLOGIC LOC WELL OWNER <br /> ORIENTATION (�) VERTICAL —HORIZONTAL —ANGLE' —(SPECIFY) Narne�0 roravA'f7e..��MA12(2t/Cbe�/Nzr TbW <br /> DRILLING N SD L FLUID WAIT!ac— Mailing Address 1351�/Je COrAM4—A FlAdI <br /> DEPTH FROM METHOD !� <br /> SURFACE DESCRIPTION C-hARJ011 NC. ZS 77 <br /> FL to Ft. De6Cribe Ineterial, grain .Size, Color, etc. CITY STATE ZIP <br /> \V �y O TI <br /> 1 1 Address z-B0 fi LrN � <br /> I t City 51-00cynil <br /> County .SAS OTO N <br /> 1 APN Book Page Parcel P`1`3-3/00 -7 <br /> t t Township Barge Section <br /> t r Latitude I I NORTHLonWEST <br /> eitue <br /> DEG. MIN. SEC. b DEG. MIN. SEC. <br /> LOCATION SKETCHAC,'IVITY (i�) <br /> t NORTH ( NEW WELL <br /> MODIFICATION/REPAIR <br /> _ Deepen <br /> _ Other(Specify) <br /> 1 DESTROY(Describe <br /> I I <br /> Phorsdumas Materials <br /> Under"GEOLOGIC LOG" <br /> ) <br /> PLANNED USES (') <br /> TWWATER SUPPLY <br /> I I Domestic _ Public <br /> Irrigation Industrial <br /> MONITORING <br /> w <br /> I I /►✓'3 • • TEST WELL <br /> 1 • •/. "J•1�-(o CATHODIC PROTECTION_ <br /> HEAT EXCHANGE_ <br /> 77 f DIRECT PUSH_ <br /> INJECTION_ <br /> VAPOR EXTRACTION_ <br /> SPARGING <br /> SOUTH REMEDIATION <br /> III usnaleir lla.,I,edrotio ee u 1Vr11 frim Ronda_Ruif....if <br /> 6,amev,Riva:r,AS B ACC n A r. Use nrlrlilinanl�n)rrr if OTHER(SPECIFY) <br /> uecaaxnnp PLEASE BE ACCURA�E L-CODIPLET . <br /> WATER LEVEL @ YIELD OF COMPLETED WELL <br /> I 1 <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFAC <.IQ,e- �p . <br /> DEPTH OF STATIC !! <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD ' (GPM) 8 TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) May not be representative of a well's long-tern]yield. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- <br /> FROM SURFACE HOLE TYPE(—) FROM SURFACE TYPE <br /> DIA. Y se ¢o nMATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN. FILTER PACK <br /> (Inched gg w GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ft. to Ft. m v cOi� (Incneal THICKNESS (Inches) Ft. to Ft. \ (TYPE/SIZE) <br /> to1 <br /> ce <br /> , I <br /> I <br /> I I <br /> I I <br /> T Geologic Log CHNIENTS (v) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> —�'- M ikf}Ci�(„ l�llnlN All <br /> cr.s Z-NL <br /> Well Construction Diagram NAME t <br /> (PERSON. M, DR CDRPDRATIDNI ITYP OR PRIMED) <br /> — Geophysical Logs) f /' ,t p C <br /> ,,So11/Water Chem -/ <br /> Chemical Analyses LO �W7 CA -75 ?, <br /> Other LOCA11 CtJ /4 P (2 ADDRESS " <br /> /u CITY ww 'f STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed L D ILLER HDW I I V� ` O� So <br /> WELRIZED REPRESENTATIVE DATE IGNEO C-57 LICENSE NUMBIR <br /> D\v'R 186 REY. It-us IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />