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OUAQRUPLICATE STATE OF CALIFORNIA DWR USE ONLY - DO NOT FILL IN <br /> For Local Requirements WELL COMPLETION REPORT <br /> Page T_of_4__ Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. 1 I_ NO. 0948170 <br /> Date Work Began!t ` �,; Ended + . LATITUDE LONGITUDE <br /> Local Permit Agency , *- t <br /> Permit No. N r t""t r•t n + APNITRS/OTHER <br /> 1 �—� �� =T. Permit Date.(; ��t. t J a ._ <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION VERTICAL —HORIZONTAL _ANGLE <br /> DING —(SPECIFY) Name_;11 <br /> METHOD �f n f- s n ! 1 Mailing Address ?'t { Cr r. r T r <br /> DEPTH FROM —-(-- �• .;=--�4 _ ..! r <br /> .,—.--� L,r� <br /> FLUID <br /> SURFACE DESCRIPTION r rf <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY STATE l Pi- <br /> I I <br /> Address <br /> WELL LOCATION <br /> '' a � r_ + <br /> I <br /> Cita: r t <br /> County t r 'r: t <br /> APN Book—I-Page E Parcel <br /> ' ' ; ' n Township Range Section <br /> Lat3"i a N Long.—1 f I u I -1W <br /> 4-- <br /> t „ f,F ty + DEG. MI . 'SEC. OEC:. MI <br /> LOCATION SKETCH ACTIVITY (�) <br /> NORTH NEW WELL <br /> ? r!^ ryaTc Irl :;t <br /> - - ., MODIFICATION(REPAIR <br /> " + Deepen <br /> v . <br /> i I <br /> Other(Specify) <br /> • - ,. t DESTROY(Describe <br /> i I I ,- F f l c{� r Procedures and Materials <br /> - + - E E E $ I, E �I A � Under"GEOLOGIC LOG") <br /> USES <br /> Q (') <br /> ` ' t A C H [ WATER SUPPLY <br /> r t' r t <br /> Domestic _ Public <br /> F Irrigation _ Industrial <br /> 1 +' H! { t fy F v ` r~ I r++„ w MONITORING <br /> + I 1- TEST WELL <br /> s 4 <br /> CATHODIC PROTECTION <br /> ♦4 t . r <br /> HEAT EXCHANGE <br /> \6./ DIRECT PUSH <br /> I I <br /> ! } 4'r` +n• .A .. F " INJECTION <br /> C ^ ,14+ {f' VAPOR EXTRACTION <br /> SPARGNG <br /> SOUTH' REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildtngs, <br /> •r' , Fences,Rivers,etc.and allach a map Use additional paper if OTHER(SPECIFY) <br /> , , necessanj.PLEASE BE ACCURATE&COMPLETE. <br /> I I <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I r <br /> t DEPTH TO FIRST WATER _(Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL A (Ft.)&DATE MEASURED _ <br /> ESTIMATED YIELD ' RI P (GPM) &TEST TYPE '- <br /> TOTAL DEPTIi OF BORING t' (Feet) TEST LENGTH(Hrs.) TOTAL DRAWDOWN �.,n(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL r, (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. x z a MATERIAL( INTERNAL GAUGE SLOT SIZE CE- BEN- <br /> (Inches) Z w z� a GRADE DIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> Ft. to A. m opo (Inches) THICKNESS (Inches) Ft. to FL (�) (�} (�) (TYPE/SIZE) <br /> e rt <br /> I I '- <br /> I I <br /> ATTACHMENTS (2�L) CERTIFICATION STATEMENT <br /> Geologic Log <br /> I,the undersigned, certify that this report is complete and accurate to the best of my knowledge and belief. <br /> j _.L. Well Construction Diagram NAME -r �!f . ��� £ - ? T_ - f !! _ _ __ - P_± <br /> {PARSON, FIFM 13 CORPORATION}' LYPED'OR PRINTED) t <br /> _ Geophysical Log(s) <br /> — Soil/Water Chemical Analyses ° !`�f C+ wt 1.- • '- .i in r! r, <br /> ADDRESS 15 STATE - ZIP <br /> �: Other �;�_; A <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed r + �� � t r - ' r ;� l�'' ' &r <br /> C-57 LICENSED WATER WEr LL CONTRACTOR T DATE SIGNED - C-57 LIC Sf NUMBER <br /> DWR tas REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br /> i <br />