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TRIPLICATESTATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL I <br /> Owner's Copy WELL COMPLETION REPORT <br /> Page of <br /> Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> — <br /> 09 Owner's Well No. :'..� /, - _ < q No. O O.!. a <br /> LATITUDE LONGITUDE <br /> Date Work Began L /� << z a > Ended �+�f��l�� `� <br /> Local Permit Agency r� . t.. P. =u,. <br /> APN/TRS/OTHER <br /> Permit No. '22 — Permit Date l 1^,1.;2 /r? <br /> GEOLOGIC LOGVILL OWNER <br /> y, <br /> ORIENTATION —VERTICAL _HORIZONTAL _ANGLE —(SPECIFY) NSllle <br /> DRILLING 1 , MatluTg Address x^ k% +..rs <br /> METHOD +f v' t r;.•.A/ FLUID Y j <br /> DEPTH FROM <br /> SURFACE DESCRIPTION - <br /> Ft. to FL Describe material, grain size, color, etc. CITY • S TE >LF- <br /> � � WELL LOCATION <br /> y -% Address 1 <br /> t , City e .) <br /> t r f j t, Coun <br /> I•r * } APN Book Page I/ ) Parcel " <br /> y,. Tovalship ,Ii RangeSection _ <br /> / Lat I 1. I " N Long - l I I Vd <br /> C.' <br /> DEG. MIN. SEDEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (2L) <br /> —•k NORTH _ r. NEW WELL <br /> MODIFICATION/REPAIR <br /> t - -�rj. - — Deepen <br /> 4—i _ Other(Specify) <br /> __L DESTROY(Describe <br /> ( t "�..�,., 'T'`, ,• ^(�^ +"`' r Procedures and Materials <br /> Under"GEOLOGIC LOG") <br /> USESO <br /> t ('. t 7 WATER SUPPLY <br /> Domestic _ Public <br /> Irrigation _ Industrial <br /> ml <br /> 3 r I i•` w MONITORING <br /> t`^.t \ TEST WELL— <br /> i CATHODIC PROTECTIC <br /> HEAT EXCHANL _ <br /> t.. DIRECT PUSH <br /> t (t INJECTION <br /> VAPOR EXTfIACTION_. <br /> -� SPARGING <br /> i REMEDIATION <br /> IAustrate or Describe Distance of WeRfrom Roads,Buildings <br /> Fences,Rivers,etc.and attach a map. se additional paper i� OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE&COMPLETE. <br /> t � <br /> WATER LEVEL &,YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER (FL) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL ft (Ft.)&DATE MEASURED <br /> i t <br /> ESTIMATED YIELD (GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORING % ` i (Feet) / rf TEST LENGTH (Hrs.)TOTAL DRAWDOWN (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL (Feet) 'May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) ANNULAR MATERIAL <br /> BORE- <br /> FROM SURFACE DEPTH <br /> HOLE TYPE(—) FROM SURFACE TYPE <br /> DIA. x z '�' MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (inches) g a DIAMETER OR WALL IF ANY FILTER PACK <br /> GRADE MENT TONITE FILL <br /> Ft. to Ft. m y (inches) THICKNESS (Inches) Ft. to Ft. (TYPE/SIZE) <br /> t <br /> I - <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> �r I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belie <br /> _ Geologic Log <br /> —ir'Well Construction Diagram NAME V. i <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR P NTED) <br /> _ Geophysical Log(s) <br /> _ Soil/Water Chemical Analyses <br /> Other ADDRESS.---•7 <br /> CITY STATE ZIP' <br /> /,>'1> i r <br /> ATTACH ADDITIONAL INFORMATION, IF JEXISTS. Sign' 1 ��, F{�A"/it. <br /> CC�ENS WAT )NELLF'L RACTOR --�' DATE SIGN C-57 UCENSE NUMBER ' <br /> DWR 188 REV.05-03 IF ADDITIONAL SPADE IS NEED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />