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ORIGINAL STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> File with DWR WELL COMPLETION REPORT <br /> Page 1 Of I Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. MW-2. No. 0948170 <br /> Date Work Began I1 0 Ended I I $ j Cf LATITUDE LONGITUDE <br /> `r Focal Permit Agency 5 AN TO VIN covkb E N b APN TRSlOTHEq <br /> Permit No. S # 00 55 } Permit Date I IDZ 0 <br /> r GEOLOGIC LOG WELL OWNER <br /> w ORIENTATION (:) 7—VERTICAL —HORIZONTAL _ANGLE —(SPECIFY) Name CP V'N 1Y 0 10Oil V I N i f r <br /> DRILLING G-L k � IT 2 L E. 4 0 is V uVE <br /> _ DEPTH FROM METHOD �� �� � FLUID 0 N� Mailing Address L <br /> SURFACE DESCRIPTION S TO C KI O N.� '- •,• •_.-_,C A 9 5105 <br /> Ft. to Ft. Describe material, grain •Size, Color, etc. CITY STATE ZIP <br /> Lr WLk OCATIQN <br /> Address -?71e`Ir. VV[_ E AVE,N•V <br /> city. <br /> County S AN TO:A QV I N <br /> ...� APN BookI-__4.2 PageIr. Parcel - 00 1 <br /> L l WA5 D E s OYQ 61 Tolffmsh, Range Section <br /> OV RILL1N(r fN I I Lat Long 111 I- $ 1 <br /> +(�) <br /> W <br /> PQ HPL .1DJNY WIT-1i <br /> - DEG. MIN. SEC. DEG, MIN. SEC, <br /> LOCATION SKETCH ACTIVITYA C 7 ILL( V- � AND NORTH _ NEW WELL <br /> NG,J..'V A ` F0LIOW- <br /> MODIFICATtONIREPAIR <br /> 5TIM A•V.Cy:. - ...S. , Deeper, <br /> Other(Specify) <br /> JOE,`• v 1�Kt 130. AND l •W E 1.4 - V DESTROY(Describe <br /> Pmcer ( p 5_I.-N_ /LWERE r r t S I T M A n Updar—GEOLOGIC <br /> and Materials <br /> Lft rl .l l J ( !'� (" ilnder"GEOLOGIC LOG") <br /> � <br /> P\kMoVEQ , <br /> USES(f) <br /> - 1 !4rl• M FACK WAS O' WATER SUPPLY <br /> ' 4Yi O Domestic Public <br /> DklUtD tt FkL- Irrigation I,dust,,al <br /> O 4 5 L LC T 2 a MONITORING-V—/ <br /> 1CEMERT O V y S I N(r A TEST WELL_ <br /> E CATHODIC PROTECTION <br /> HEAT EXCHANGE <br /> � I SVP\ <br /> PUSH <br /> 1 • (_vWAS O INJECTION <br /> _ -F o c PATCH <br /> VAPOR EXTRACTION_ <br /> ' i r A -+ 1 GU C SPARGING <br /> LDYED B * 0 MATh SOUTH REMEDIATION <br /> I F C Illustrate or Describe Distance of lVell front Roads,Buildings, <br /> 5\j. O 1 - Ricers, <br /> Fences, etc.and attach a nu;p VL5C additional paper if OTHER(SPECIFY} <br /> V t Sir neces'sanf.PLEASE BE ACCURATE&COMPLETE. <br /> � I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> r <br /> DEPTH TO FIRST WATER 12'9 (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC rr Q j <br /> t WATER LEVEL.... L (Ft.)&DATE MEASURED r `0 <br /> ' N - (GPM <br /> +.�� rr ESTIMATED YIELD ' ) &TEST TYPEN A <br /> 1 <br /> TOTAL DEPTH OF BORING (Feet) TEST LENGTH A (Hrs.)TOTAL DRAWDOWN_.N A (Ft.) <br /> y <br /> TOTAL DEP'T'H OF COMPLETED WELL May not be representative of a well's long-term yield. <br /> DEPTH CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE BORE- TYPE( ) FROM SURFACE TYPE <br /> r.+r HOLE <br /> DIA. Y w ¢o a MATERIAL/ INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches} = zF a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> oc� .., Ft. to Ft. (TYPE/SIZE) <br /> FL to Ft. g v c>> (Inches) THICKNESS (Inches) ,� ,� ,� <br /> o l._) (—) (_) <br /> 0 5 8 ✓ I PVC 2 S Cid 40 0 '2 ✓ ~ <br /> `r 2 8 ✓ PvC 2 ScH 40 0 .010 .2 I4 ;/ .. <br /> 4 15 ✓ 1 43 SAN <br /> I <br /> w <br /> 1 <br /> ATTACHMENTS (vL) CERTIFICATION STATEMENT <br /> I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Geologic Log <br /> Well Construction Diagram ,,t= 1051F PH KAMA(-E FOIi ALL WtIL AGANDONMENJ <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> ' _ Geophysical Log(s) <br /> Soil7WaterChemical Analyses 6626 MERCej4AN9kSt WAY, DiAMONp SPLIT Q CA 95619 <br /> r.r <br /> Other S 1 T E M A p ADDRESS CITY STATE ZIP <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed It 'Z„6 <br /> C-57 LICE ED WATER WELL COITRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> u <br /> Dwn 168 REV. o5-w IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM OSP 03 76036 <br />