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QUADRUPLICATE STATE OF CALIFORNIADWR USE ONLY — DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page t of I Refer to Instruction Pamphlet STATE WELL NO./STATION N0, <br /> Owner's Weft No. No. 0948169 <br /> Date Work Began %t $ G _, Ended Ii 549 LATITUDE LONGITUDE <br /> Local Permit Agency ; K j�A Cho 11',jVt1 i y � H p <br /> ,%i Permit No. >r �-16 1 Permit Date t APN/TRS/OTHER <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (✓) JL VERTICAL —HORIZONTAL —ANGLE �i 4- �. <br /> DRILLING e —(SPECIFY) Name T (� ft L�1t <br /> DEPTH FROM METHOD r } �' V FLUID u il Mailing Address. L j S li t i�V <br /> SURFACE DESCRIPTION > 1 L t A > t ; <br /> Ft. to FL Describe material, grain Size, Color, etc. CITY - - STATE ZIP <br /> r r Address WELL,LOCATION <br /> k % .1e . r11lr i `Jf <br /> City it= ICPf <br /> I - <br /> County L A i I N <br /> APN Book Page f U Parcel I <br /> f LL W A S C I s i jk.C YL ( y Township Range Section ~ <br /> r y e lg 'L N� r T I r l fk Lat ; 9 � 3 3 N Long <br /> 1 o t R`r H 4 I. t M P:I D l.A 3 I1.!fr %I[ H DEG. MIN. SEC. DEG. MIN. SEC. <br /> I t I N a l G A T,}I) LOCATION SKETCH ACTIVITY (�) <br /> NORTH <br /> NEW WELL <br /> T <br /> r �1 MODIFICATION/REPAIR <br /> r ! t 1 A u t �a.� — Deepen <br /> Other(Specify) <br /> r I T E1 t(� {r � I nt fi VL L `,N t LL X DESTROY(Describe <br /> r i �S,t y NIA I 1A 1.Cj Vl t A ` Procedures and Materials <br /> r Al M L`' t ,( F A N N V t A y SEE , � ( 1 "1 <br /> Under"GEOLOGIC LOG"; <br /> h A Y lY ni rt h CH 1 i I f(+.I p f T{ f USES('') <br /> r r 7 i A 1`'t. 'J f f I.t E PACK \AAS I ! A_ cr�1 C (� WATER SUPPLY <br /> U t�I L L l p 'r vi ,! �} 1 !'I(,' 'Z r' [ _ P" 1 6 Y _ Domestic _ Public <br /> �� ` R 5 I_ R fru 11 F N f R T Irrigation Industrial <br /> wMONITORING V <br /> CtE `1ENr T� CVr VSIN & A TEST WELL <br /> CATHODIC PROTECTION— <br /> t I HEAT EXCHANGE <br /> Vill A 1; 2 � ��/, x L 0 DIRECT PUSH <br /> t�L ti i�t-LF,`! INJECTION <br /> I I <br /> vin� 1 A v(r I Fi t G h P A I L H VAPOR EXTRACTION <br /> I I ii., y i AM - V; l y, !�C N C R E i t SPARGING_. <br /> ! i+ - I rt I C H7 SOUTH REMEDIATION <br /> 1. �/ Illustrate or Describe Distance of Well from Roads,,Buildings, <br /> I \I �� P � V I D ; Nf 7 A y P}IAL Fences,Ricers,etc.and attach a vnap Use additional paper if OTHER(SPECIFY) <br /> necessanj.PLEASE BE ACCURATE v COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> DEPTH TO FIRST WATER 1�' (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC �} <br /> WATER LEVEL �'Dr� (Ft.)&DATE MEASURED <br /> ESTIMATED YIELD _ I�t + <br /> r L3` (GPM) &TEST TYPE A <br /> ' <br /> TOTAL DEPTH OF BORING —(Feet) <br /> TEST LENGTH (Mrs.)TOTAL DRAWDOWN i't A (Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL L (Feet) May not be representative of a well's long-term yield. <br /> DEPTH BORE- CASING (S) DEPTH ANNULAR MATERIAL <br /> FROM SURFACE HOLE TYPE('') FROM SURFACE TYPE <br /> DIA. Y z ¢ a MATERIAL I INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) a z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to Ft. Q m coo LL (Inches) THICKNESS (Inches) Ft. to Ft. (�) (�) (�) (TYPE/SIZE) <br /> S 2 $ y 2 ScH yo frt 2 r r <br /> I <br /> ATTACHMENTS CERTIFICATION STATEMENT <br /> Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief. <br /> Well Construction Diagram NAME TO S E P R R A M A Cr E ; L IN A LL W t LL A a A N 0:,l•i !`vI t ;!T <br /> Geophysical Log(s) (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Soil/Water Chemical Analyses C Ufo M E R C H A N D I S F- Vv A) D i A ML hip ; P R I M e1 „A ; 4: 19 <br /> Other 3 t r ADDRESS CITY STATE Si ZIP <br /> ✓r <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed t 'fy� ^'�j� I I L I � - ' `t 4 i 7 d <br /> C-57 LICENSED WATER WELL CONTRACTOR it DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV-05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />