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TRIPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> .Owner's Copy WELL COMPLETION REPORT <br /> Page_of Refer to Instruction PamphletSTATE WELL NO./STATION NO.. <br /> Owner's Well No. 2, 61 No. 0917807 I I t I <br /> Date Work Began ' b, Ended ��/f: � LATITUDE LONGITUDE <br /> Local Permit Agency r. — r. = ;; ,: i' . I— -- I I I I I � I I I I I I <br /> APN/TRS/OTHER <br /> Permit No. %`r Permit Date ! .� <br /> GEOLOGIC LOG LL OWNER <br /> ORIENTATION VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name <br /> DRILLING la 1/ <br /> METHOD FLUID Mailing Address <br /> DEPTH FROM ' ''' g <br /> SURFACE DESCRIPTION <br /> FL to Ft. Describe material, grain size, color, etc. CITY STATE ZIP <br /> WELL LOCATION <br /> Address: <br /> City71 •r'r / O r <br /> County <br /> ' APN Book Page Parcel <br /> ' Township' "rQ Range i, t t Section <br /> I Lat -, I ` ..I , � N Long- ; , I ^ I ,� % W <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> ` LOCATION SKETCH - ACTIVITY (�) <br /> NORTH NEW WELL <br /> MODIFICATION/REPA)R <br /> _ Deepen <br /> _ Other(Specify) <br /> t ail <br /> ^-DESTROY(Describe <br /> Procedures end Materials <br /> Under"GEOLOGIC LOG") <br /> USES(�) <br /> WATER.SUPPLY <br /> - :S � Domestic Public- <br /> F �` r,,•, , Irrigation Industrial <br /> ¢ MONITORING <br /> r 4 <br /> TEST WELL—_ <br /> t - i1•, a' P'I_y 7}-- CATHODIC PROTECTIC <br /> t 11 _i +�;•.., ��- _-•_•-ITS—J , HEAT F-XCHANL <br /> DIRECT PUSH <br /> INJECTION_. <br /> i VAPOR EXTRACTION <br /> SPARGING—_ <br /> SOUTH REMEDIATION—_- <br /> illustrate or Describe Distance of Well from Roads,Buildings, <br /> i Fences.Rivers,etc.and attach a ma .Use additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> i l <br /> t � <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> l DEPTH TO FIRST WATER_1 �.:t (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> t ESTIMATED YIELD' :, 114 (GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH "f (Hrs.)TOTAL DRAWDOWN ! (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE('—') I FROM SURFACE TYPE <br /> DIA. x zuy a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) or a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft to Ft. m N LL (inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (�) (TYPE/SIZE) <br /> f , <br /> � I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belie <br /> —� Geologic Log t <br /> Well Construction Diagram NAME <br /> (PERSON, FIRM,OR CORPORATION) (TYPED PR PRIMED) <br /> Geophysical Log(s) n i A y i <br /> _ SoiVWater Chemical Analyses ,L, <br /> Otherr ADDRESS _ CITY STATE ZIP <br /> t� <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed 7 ___ <br /> C-57 SED WA DWELL CONTRACTOR DATE SIGNED C-57 LICENSC NUMBER <br /> DWR 188 REV,05-03 IF ADDITIONAL S cm-ii NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />