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QUADRUPLICATE STATE OF CALIFORNIA DWR USE ONLY — DO NOT FILL IN <br /> FOY Local Requirements ELL COMPLETION REPOR' I I I I I I I I I I I <br /> Page of Refer to Instruction Pamphlet STATE WELL NO./STATION NO. <br /> Owner's Well No. No. 0917820 <br /> Date Work Began Ended LATITUDE LONGITUDE <br /> Local Permit Agency .. .-f 'II APNlTRS/OTHER <br /> Permit No. Permit Date <br /> GEOLOGIC LOG WELL OWNER <br /> ORIENTATION (i�.) —VERTICAL —HORIZONTAL —ANGLE (SPECIFY) Name <br /> DRILLING Mailing Address <br /> DEPTH FROM METHOD FLUID g <br /> SURFACE DESCRIPTION <br /> Ft. to Ft. Describe material, grain size, color, etc. CITY STATE ZIP <br /> WELL LOCATION <br /> Address <br /> City <br /> County <br /> APN Book Page 6T Parcel <br /> Township r Range Section <br /> Lat - I I N Long I I W <br /> DEG. MIN. SEC. DEG. MIN. SEC. <br /> LOCATION SKETCH ACTIVITY (.�L) <br /> I i NORTH NEW WELL <br /> MODIFICATION/REPAIR <br /> Deepen <br /> _ _ Other(Specify) <br /> DESTROY(Describe <br /> Procedures and Materials <br /> - Under"GEOLOGIC LOG") <br /> _ USES <br /> I I WATER SUPPLY <br /> — Domestic Public <br /> I I Irrigation Industrial <br /> to <br /> H F <br /> I I 3 w MONITORING <br /> I I TEST WELL <br /> CATHODIC PROTECTION <br /> I I j — HEAT EXCHANGE <br /> I I DIRECT PUSH <br /> INJECTION <br /> VAPOR EXTRACTION <br /> I SPARGING— <br /> I I SOUTH REMEDIATION <br /> Illustrate or Describe Distance of Well from Roads,Buildings, OTHER(SPECIFY)_ <br /> Fences,Ricers,etc.and attach a mtp. se additional paper if <br /> necessary PLEASE BE ACCURATE&COMPLETE. <br /> WATER LEVEL & YIELD OF COMPLETED WELL <br /> I I <br /> DEPTH TO FIRST WATER (Ft.) BELOW SURFACE <br /> DEPTH OF STATIC <br /> WATER LEVEL (Ft.)&DATE MEASURED <br /> I <br /> ESTIMATED YIELD ' (GPM) &TEST TYPE <br /> TOTAL DEPTH OF BORING _(Feet) TEST LENGTH(Hrs.) TOTAL DRAWDOWN_(Ft.) <br /> TOTAL DEPTH OF COMPLETED WELL 4T_(Feet) May not be representative of a well's long-terra yield. <br /> DEPTH BORE- <br /> CASING (S) DEPTH ANNULAR MATERIAL FROM SURFACE HOLE TYPE(—) FROM SURFACE TYPE <br /> DIA. Cz ¢ a MATERIAL/ INTEflNAL GAUGE SLOT SIZE CE- BEN-(Inches) � GRADEDIAMETER OR WALL IF ANY MENT TONITE FILL FILTER PACK <br /> � Ft. to Ft. (TYPE/SIZE) <br /> Ft. to Ft. >o LL (Inches) THICKNESS (Inches) <br /> V <br /> � I <br /> i <br /> I I <br /> I I <br /> ATTACHMENTS (.�L) 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 NAME <br /> (PERSON, FIRM, OR CORPORATION) (TYPED OR PRINTED) <br /> Geophysical Log(s) <br /> _ Soil/Water Chemical Analyses <br /> ADDRESS CITY STATE ZIP <br /> Other <br /> ATTACH ADDITIONAL INFORMATION, IF IT EXISTS. Signed <br /> C-57 LICENSED WATER WELL CONTRACTOR DATE SIGNED C-57 LICENSE NUMBER <br /> DWR 188 REV. 05-03 IF ADDITIONAL SPACE IS NEEDED, USE NEXT CONSECUTIVELY NUMBERED FORM <br />