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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 Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No.—i .' r i > ; No. 0917808 <br /> LATITUDE LONGITUDE. <br /> Date Work Began f j,T Ended_,>46I ?11 <br /> Local Permit Agency ; !.. 44DI I I I <br /> APN/TRS/OTHER <br /> Permit No. - ` ;} Permit'bate <br /> GEOLOGIC LOG LL OWNER <br /> r' <br /> ORIENTATION `VERTICAL _HORIZONTAL _ANGLE _(SPECIFY) Name., <br /> DRILLINGAti a <br /> DEPTH FROM METHOD I r : FLUID M v11ng l ' <br /> SURFACE DESCRIPTION <br /> Describe material, rain size, color, etc. `-CIT( •" , STATE <br /> FL to Ft. g �" WET'L LOCATION <br /> unty'}I�.� , ' ,,e <br /> ' l APN Book ' ;� t Page Parcel <br /> I. <br /> ' ' I4,1 Township vu Ranger Section <br /> a fat I Long — , W <br /> -DEG`. MIN: S DEG. MIN: SEC. <br /> LOCATION SKETCH ACTIVITY (!) <br /> h NORTH NEW WELL <br /> ' MODIFICATION/REPAIR <br /> ' y..r, '�Y '`" i `�...�! ; r•.re Deepen <br /> _.... _ Other(Specify) <br /> __L­"DESTROY(Describe <br /> r %( v✓� �i� Procedures and Materials"i Under"GEOLOGIC LOG") <br /> USES <br /> i �.:::...'• ',� - <br /> WATER SUPPLY <br /> i <br /> Domestic Public <br /> Irrigation - Industrial <br /> 3�.I' y .YY V t11t ,,� Q MONITORING— <br /> TEST WELL <br /> CATHODIC PROTECTV <br /> HEAT EXCHANL _ <br /> 1 I r <br /> T I / DIRECT PUSH <br /> T INJECTION <br /> ' ! °' Y F •t 41:11'i t VAPOR EXTRACTION <br /> 1' ~ SPARGING— <br /> SO�TH REMEDIATION <br /> Illustrate or Describe Dist7ififtgf W49 rn Roads,Buildings, <br /> Fences,Rivers,etc.and attach a map Use additional paper if OTHER(SPECIFY) <br /> necessary:PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER_(Ft.)BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL F1,! F (FL);&DATE MEASURED <br /> ): I ESTIMATED YIELD• -(GPM)&TEST TYPE <br /> TOTAL DEPTH OF BORING :< �` (Feet) TEST LENGTH—J, (Hrs.)TOTAL DRAWDOWNj - f;j-(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL <br /> •'s� (Feet) May not be representative'of a well's long-term,yield- <br /> DEPTH <br /> HOLE CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE( FROM SURFACE TYPE <br /> ( <br /> DIA. Y w ¢o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- 8EN- <br /> t (Inches) Z w Z F a DIAMETER OR WALL IF ANY FILTER PACK <br /> Ft. to Ft. 5 oma= GRADE Ft. to Ft. MENT TONITE FILL (TYPE/SIZE <br /> m o LL (Inches) THICKNESS (Inches) ) <br /> L I I <br /> I <br /> ATTACHMENTS (.2:�) CERTIFICATION STATEMENT — <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belie <br /> —,"Ideologic Log <br /> 1. _t Well Construction Diagram NAME 14f (,• t . ./f r� _ r ' r"�1> 1 <br /> (P 0 ;'FIRM, CO PO ATION)F PE CrPRI tTEb) F^ ' { d��r F—% ' <br /> _ Geophysical Log(s) ' <br /> _ SoiVWater Chemical Analyses / <^ y--��i' t r tJ '' �—'' t +'t s �" C714 <br /> Other /s ADDRESS CITY f STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed '—V <br /> WA ELL S00tTok DTE,IGNED C-57 'CENSE NUI IBER <br /> r DWR 188 R9.05-03 IF ADDITIONAL IS N & USE NEXT CONSECUTIVELY NUMBERED FORM <br /> V <br />