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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> L.t Page I of I Rrfer to Instruction Pamphlet STATE WELL NO./STATION NO <br /> Owner's Well•. No. +-y W- f No. 0948169 <br /> Date Work Began 11 0 Ended 11 /B10% LATITUDE LONGITUDE <br /> Local Permit Agency WA TOAM11i Cov N <br /> Permit No. 5 00 S 5-+6 I Permit Date (0 Z 4 To—t— APNITRS(OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> y ORIENTATION (V) I VERTICAL —HORIZONTAL —ANGLE —(SPECIFY) Name C Q:U N t 1_ SA 14 10A 440114 <br /> DRILLING apii S U 71; C C V <br /> DEPTH FROM METHOD Il G IF 9 FLUID N 0 K E_ Mailing Address f 5. T 1S A CNV E <br /> SURFACE DESCRIPTION S 0Gh 0- _ CA ,D5205 <br /> Ft. to Ft. Describe material, grain size, color, etc.� CITY _ � 1... WEOVTIO STATE ZIP <br /> Address_Z 11 I= WU_It f} VE N V E <br /> city, 5T0C6T0N <br /> County S Of-9 <br /> �'0 R V I N <br /> �t :APN L <br /> Book�✓W Page t 6 Parcel 00( <br /> W L LL WAS - OYL q .i3 Township Range Section <br /> I I 0V _ bKILLI-NCr rt` - •1 litl.R�E -Lat 31 1 951 V3_ N Gong -1-41 1 Z9 1 76 <br /> w <br /> i 1'I 4 tf.0 H o 1,t 1 l`A e , WITH <br /> ? DEG. MIN. SEC. DEG, MIN. SEC. <br /> u Av <br /> CNE-15 V 1 i t1 N J R 1G- A iN b LOCATIONNORTH KETCH ACTIVITY (—I) <br /> I I \L <br /> NEW WELL <br /> N G I Arr, .E. . 0 LLQ W ' MODIFICATION/REPAIR <br /> MIM M AV Cr G9.5. Deepen <br /> - Other(SpeWy) <br /> yJ I I <br /> t E STREtT 00)( AHO •` IL + L L DESTROY(Describe <br /> C I '�i e b C Procedures and Materials <br /> J <br /> ' A V A L Under"GEOLOGIC LOG") <br /> ZEMOV D {- I NNVLAR SEE SITE NIA P USES (II <br /> `� S L A N b r 11-( A G W AIT A C H E-D WATER SUPPtY <br /> 1 !1 I/ <br /> 1 ILL T t — - Drmgsooc _ Public <br /> Will <br /> c `,�1 T /� r IrrigaliPn Industrl I <br /> I L I✓ W/7 ) L L(< yY { IlLwLj Q MONITORING <br /> ham/ <br /> CEMENT . G O V TEST WELL <br /> CATHODIC PROTECTION <br /> i HEAT EXCHANGE <br /> I �t 1` r `C' rel A S - S O 1� DIRECT PUSH <br /> S <br /> � `'r /y /'� Ph <br /> /� INJECTION <br /> W A O V rm f[ C/ VAPOR EXTRACTION <br /> 1 A V I CONCRtlt SPARGING .� <br /> D i f• /D t 11 SOUTH REMEDIATION <br /> ` l- V V 1 CI Illustrate or Describe Distmtce of Well from Roads,Buildings, <br /> V I A Fences,Riuers,etc.and vaneh a nea . se additional paper if OTHER(SPECIFY) <br /> necessary.PLEASE BE ACCURATE dr COMPLETE. <br /> I 1 <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I 1 <br /> DEPTH TO FIRST WATER 1� V (Ft.) BELOW SURFACE <br /> I r <br /> DEPTH OF STATIC �{ Q <br /> WATER LEVEL I�p�,�V (FL)& J 8 TEST TYDATE MEASURED It <br /> ESTIMATE=D YIELD O V <br /> ` A(GPM) N <br /> AA__ <br /> A <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH 1�.-Li(His.) TOTAL DRAWDOWN NA__(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL :2- (Feet) "May iaot he representative of a well's long-term yielr(. <br /> CASING (S) DEPTH ANNULAR MATERIAL <br /> DEPTH BORE- FROM SURFACE TYPE <br /> FROM SURFACE HOLE TYPE <br /> y DIA. z ¢ w INTERNAL GAUGE SLOT SIZE CE- BEN-w O a MATERIAL/ FILTER PACK <br /> (Inches) a w fir- a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL <br /> Ov <br /> Ft. to Ft. (TYPE/SIZE) <br /> Ft. to FI. m u (Inches) THICKNESS (Inches) <br /> Q 5 8 PVC 7- i SCN o 4 2 <br /> PVC 2 ' SCA t] o.OZO 2 1 ✓ - <br /> 15 ✓ #3 SA �4b <br /> I ` <br /> I 1 <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> / I, the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> tr Geologic Log <br /> ✓ Well Construction Diagram NAME?0 EPN R A M A fl•E F O K AU L W t L E ABANDONMENT <br /> (PERSON, FPoRM, OR CORPORATION) (TYPED OR PRINTED) <br /> _ Geophysical Log(s) <br /> Soillwaleer Chemical Analyses 6 62 6 M E P,c N A N D I s f_ w AY DIAMOND S P I N G-S GA 9 S 619 <br /> '� Other S 1T E MAP ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION. f 11F!T XISTS. Signed i 1 Z 5 4.B S 59 <br /> C-57 LICE ED WATER WELL CO RACTOR OATS IGNEO C-57 LICENSE NUMBER <br /> DWR 188 REV, 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM f:�==? OSP 03 78836 <br /> r.r <br />