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'The free Adobe Reader may be used to view and complete this forth. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do Not Ril In <br /> Page 1_ of / Well Completion Report <br /> Refertu/nsfnx im Pamphlet State Weil Number/Site Number <br /> Owners Well Number N XXXXXXX W <br /> Date Work Began /O _ Date Work Ended Latitude Longitude <br /> Local Permit Agency <br /> Permit Number !&2D-7 54, O Permit Date APN/TRS/Omer <br /> Geologic Log Well Owner <br /> Orientation OVertical 0Horizontal OAngle Specify Name <br /> DrIIII Method Drilling Fluid o n ��. rj, <br /> Depth from Surface Description Mailing Address o� �l � <br /> Feet W Feet Describe material, rain size,color,etc Ci 5-r..�'�'�,pv� Sta a 2 d. 7I r a' <br /> o ^ Well Location <br /> O o Yt Address & N . S 2 k' �'�' _ j �� <br /> ` City's* ir. i CA . `f County &I i <br /> a Latitude N Longitude __�N <br /> (�i J b Dea. Min. Sec. Dau. Mh. Sac, <br /> / /70 F a iI d Datum Dec.Lat. Dec.Long. <br /> rJ /9'3 APN Book Page Parcel <br /> f 6 Township -Range Section <br /> (o a.05 Location Sketch Activity <br /> D $ -;Isketch must be dra.by hardaft ,femis hied. �I%AkWell'�rPlOk <br /> -/0 IlaNorth O Modification/Repair <br /> /O5 Jd• S b��e O Deepen <br /> �"'�d / O other <br /> `jj 3 '/ eA V O Destroy <br /> ���yyy cesenea wac.dums am n,aredals <br /> -4&7 � // ., uMc'GEOLOGIc LOG' <br /> Z75 o .t rcS Planned Uses <br /> r,7 8 ' water Supply <br /> []Public <br /> a�4 .. T�Domestic <br /> Imgation ❑Industrial <br /> e{"IG O Cathodic Protection <br /> O Dewatering <br /> ' O Heat Exchange <br /> �( 0Injection <br /> O Monitoring <br /> O Remediation <br /> 5lyI z O Sparging <br /> South O Test Well <br /> auso-aa u,desmea asvuam.ea ,IaaLiryp, O Vapor Extraction <br /> m�:.els.aye asasn a mea Use aaumae reoa+aMre.,ry. O Other <br /> Please m aucumc and umm ere. <br /> ater Level and Yield of Completed Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Total Depth of Boring 30 D Feet Estimated Yeld (GPM) Test Type <br /> Total Depth of Completed Well j D c7 Feet Test Length (Hours) Total Drawdown (Feet) <br /> *May not be re resentative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type if Any Surface Fill Description <br /> Feet to Feet Inches inches Inches Inches Feet to Feet <br /> -z r . _ /4 V eye- 1 ,5160 SK 540,P/ <br /> -( <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 _H +-� E/liY <br /> ❑ Geophysical Log(s) _ CA <br /> Parse',Firm ego pea _ <br /> tSta/on <br /> ElSoil/Water Chemical Analyses Aaaress <br /> ❑ Other Signed '' y /.C/" City <br /> alk7'79L' <br /> Attach addiwnainformation K it exists. G57 Umpolied water well Cart *v Datle Signed C-57 License Number <br /> DWR 188 REV.1/2006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />