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Q��C0�u 7v'r1l1 u <br /> The free Adobe Reader may be used to New and complete this form. Hovnver,software must be purchilUtCodlflp e,9 reuse a saved form. <br /> File Original with DWR State of Califomlarnll llnnnt1 Use -Do Nd Fill In <br /> Page _(_ Of ( Well Completion •IGC�I(F_Yf;Mit�AiyIFIVtn7Tr <br /> RCarro roebu;lgr Pampltlet � I�I Stale Well NumberSite Number <br /> Owners Well Number W` No. 16 <br /> Date Work Began �Z �05 Date Work Ended 71'."T5,0 <br /> La6lude Lon fade <br /> Local Permit Agency <br /> Permit Number <br /> O Permit Date <br /> �L2�P7' APNrtRSlOUrer <br /> Geologic Log <br /> Well' mer <br /> Orientation qVertical / O Horizontal OAngle Spec fy Name /AI <br /> Dnlling Method 4M Drilling Fluid Mailing Address�5 qS J " W �NI�a n rV L/'[ <br /> Depth from Surface Description ����� Bare i 9D� <br /> Feet a Feet Describe Material. rain she,color,etc -C' <br /> WellLocation <br /> Address <br /> . City •• County <br /> Lalgude N Longitude ___W <br /> Dia. Nin. "Sec Dee. Mm. .aec <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Parcel <br /> Township Rana Section <br /> Locations " .t ACtiVi <br /> f 7 U i K tsxetrn man ee aae+r M nand, "Is roe Q New Well <br /> Q ModifipticnlRepair <br /> O Deepen <br /> O Other <br /> r L•� `� �` Destro <br /> p�m,�aeme�.na. <br /> ' 1 '., u,Mr'aEgAaIC L06' <br /> ` Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> y <br /> Q Cathodic Protection <br /> Q Dewatering <br /> [ � Q Heal Exchange <br /> Q Injection <br /> Monitoring <br /> Q Remediation <br /> JI. ft A O Sparging <br /> 0 Test Well <br /> aiAe.e.era:wltieaa.vatwekoYn ,woo. O Vapor Extraction <br /> m..,.c aM.Xamamo u...aaaw r.c..r.m�r.. O other <br /> water Level and Yield of Completed Well <br /> Depth to first water (Feet b surface) <br /> Depth to Static <br /> Water Level (Feet) Measured <br /> Total Depth of Boring Feet Estimated Yield' ) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours)Total Drawdown_(Feet) <br /> 'Ma not be five of a well's ton tens yield. <br /> --Ea—sings s Annular Material <br /> Depth from Borehole wall Outside Screen Slot Size Depth from <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface FIII Dasodptlon <br /> Feet to Feet laches Inches Inches Inches Feet to Feet <br /> A chments CoMfication StateirpentCertification <br /> ❑ Geologic Log I,the undersigned, t71a this,11rt' 7,lete p to to Ote best of my knowledge and belief <br /> ❑Well Construclio iagram 1Vame J6 v� v� <br /> Pe F.or CA <br /> y. <br /> ❑ Geuphysica (s) (,y sum <br /> ❑Sol mical Analyses ' <br /> ❑O CheSigned 4W, N/ lieu <br /> Amthsd Iriam.Uon a It east,: csTu I.edwaierwNCamaoeer D n C-57 License Number <br /> D1M 18e REV.1r000 IF ADDITIONAL SPACE IS.NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />