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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 NOJSTATION NO. <br /> Owner's Well No. "� Tr-IL r=%-}!, rG No. V J.i [ <br /> Date Work Began _ Ended �� 810 <br /> LATITUDE LONGITUDE <br /> Local Permit Agency ! >; d I I I I <br /> ' � APN/TRS/OTHER <br /> Permit No. 41 42— <br /> GEOLOGIC LOG' LL OWNER <br /> ORIENTATION ` ZVERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name 3 r.'r <br /> DRILLING <br /> DEPTH FROM METHOD FLUID Mailing ArlrlrPct`' �`i <br /> SURFACE 'brESCRIPTION . ' !vl ' �- <br /> Ft. to Ft. Describe material, grain size, color, etc.:,. �,�r,LLI_ OCATION TE <br /> c .� <br /> ul <br /> 'y v <br /> Book Page L�Parcel <br /> i 11 Township f Range 474 <br /> Section ^ <br /> Lat �, ,.N Long- / i w <br /> " DEG. MIN' C: DEG. MIN.' SEC. <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH <br /> �f NEW WELL <br /> MODIFICATION/REPAIR <br /> t t �:, "--.,` ; ':� i,,• :�G• �. .— Deepen <br /> ' — Other(Specify) <br /> t fIt�Al <br /> f <br /> DESTROY(Describe <br /> C , Procedures and Materials <br /> j ' ,4L'^-•-"'' •+�—'-"" Under"GEOLOGIC LOG") <br /> ! USES(iL) <br /> •, ti WATER SUPPLY <br /> Domestic Public <br /> Irrigation Industrial <br /> -... MONITORING_ <br /> 1 <br /> TEST WELL <br /> CATHODIC PROTECTI( <br /> HEAT EXCHANL _. <br /> DIRECT PUSH <br /> INJECTION <br /> / VAPOR EXTRACTION <br /> �- - SPARGING <br /> REMEDIATION <br /> Illustrate or Des ' eustance of,-.SYell from Roads,Buildings OTHER(SPECIFY)_ <br /> Fences,Ricers,etc.and attach a se additiondl paper i� <br /> necessary.PLEASE BE ACC URA E&COMPLETE. <br /> t , ' <br /> s WATER LEVEL &YIELD OF COMPLETED WELL <br /> y DEPTH TO FIRST WATER '•/1i�T(FL) BELOW SURFACE <br /> { i DEPTH OF STATIC <br /> r WATER LEVEL I- (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD' (GPM)&TEST TYPE— <br /> TOTAL <br /> YPE TOTAL DEPTH OF BORING (Feet) TEST LENGTH (Ft.) <br /> - (Hrs.)TOTAL DRAWDOWN <br /> TOTAL DEPTH OF COMPLETED WELL A6 (Feet) May not be representative of a,well's lang-term yield. <br /> I <br /> & DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- <br /> HOLE TYPE( FROM SURFACE TYPE <br /> DIA. x zW a MATERIAL/ INTERNAL GAUGE SLOT SIZE CTE� BEN- <br /> (Inches) z w¢ z a GRADE DIAMETER OR WALL IF ANY MFILL FILTER-PACK <br /> Ft. to Ft, m o �_ (Inches) THICKNESS (Inches) Ft. to .Ft. (TYPE/SIZE) <br /> y LL ( �) (�) <br /> r. <br /> I. <br /> t , <br /> ATTACHMENTS (✓) CERTIFICATION STATEMENT <br /> I, the undersigned,certify that this report is complete and accurate to the best of my knowledge and bdlie <br /> Geologic Log <br /> -Well Construction Diagram NAME ' l J.r. •t`•• ! Y1+ . , . / <br /> r g F RM, R ORATIO ) (TYPED OR PRI D) �i 1 f—ii i- <br /> - <br /> A <br /> � _ Geophysical Log(s) <br /> r — Soil/Water Chemical Analyses t y �y� �t` � .,�/ �. r f� 11/1 J' <% <br /> Other t r ADDRESS CITY' STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF t EXISTS. Sign Bd (1112 jfT <br /> C-57 E CO TAR AYES N C-57 IC SE'NIl BER <br /> DWR 188 REV.05-03 IF-ADDITIONAL SP CE IS NEEDE[�, USE NEXT CONSECUTIVELY NUMBERED FORM <br />