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The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,saw:,and reuse a saved form. <br /> File Original with DWR State of California DNR Use On -Do Not Re In <br /> Page Of Well Completion Report <br /> Rebrb Mseu:e'on Pdmpmla State Well Numtitiffore NuimbeT <br /> • Owners Well Number No•X�0o0�9so2�7 <br /> Date Work Began o Date Work Ended Latitude Longitude <br /> Local Pennft Agency -- <br /> Permit Number 0';-77&5- Penn Date �! - aPN/rR5/Other <br /> Geologic Log Well Owner <br /> Orientation •Vertical O Horizontal OArgle Spedty Name C! O <br /> Drilling Method 4 Drilling Fluid Mailing Address Z09 V.S <br /> Depth from Surface Description C. �f;�` State L <br /> Feet m Feet Describe material, rain size,color,etc <br /> Wali location <br /> L Address / 66 <br /> City -ro c .-. P4 County SA- Tots 4r <br /> Latitude N'Longitude _w <br /> �G i 6U Gc leaMin. Sac. Deo. Mtn. Sen <br /> r Datum Decimal Lat. Decimal Long. <br /> a: <br /> AVN Book Page _ Parcel <br /> . Townshi Range Section <br /> Location Sketch Activity <br /> Itekhrrust0e drawn bherld anerfam ls. ted. -QNew Well <br /> O Modificafion/Repair <br /> PSI0 Deepen <br /> r\ O Other <br /> Destroy <br /> urge'GE0.0GCLW' <br /> PlannedUses <br /> _..___-- _.._.._- O Water Supply <br /> `A ❑Domestic []Public <br /> ❑Irrigation ❑Industrial <br /> I�� 9 <br /> � Q.Cathodic Protection <br /> • '� r O Dewatering-� O Heat Exchange <br /> O Injection <br /> '��'��`� 1♦Monitoring <br /> O Remediation <br /> O SpaTest W g <br /> O Test <br /> Q Vapor Extraction <br /> ar,eweaNaubaYlwe.a+er tori m.ar,y,4gae,lartm, Q Other <br /> Water Level and Yield of Completed Well <br /> Depth to first water (Feet urface) <br /> Depth to Static <br /> Water Level F ate Measured <br /> Total Depth of Boring eet Estimated Yield` (GPM) Test Type <br /> Total Depth of Completed Feet Test Lengt (Hours)Total Drawdown_(Feet) <br /> 'Ma not be representative of a well's to term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Sire Depth from <br /> Surface Dlametsr Type Malarial Thickness Diameter Type BAny Surface FlII Description <br /> Feel w Feet Inches Inches Inches Inches Feet.to,Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log 1,the undersigned,ce ' ihetthis r is plate and w ccu to to the best of my knowledge and belief <br /> ❑Wall Construction Diagram Name V L , _ <br /> ❑Geophysical Log(s) Brion or n Gam' .try CA m. <br /> ❑SoNWater Chemical Analyses [(957459--• <br /> ❑Other Signed tl n ��{�t*L— <br /> Aeadl aatl veld mmesae tl eevNe. CS] 'coned Water Wer ConVedor Dg f1Ed C.57 License Number <br /> OWR 188 REV.1120015 IF ADDITIONAL SPACE IS NEEDED,USE NEM CONSECUTIVELY NUMBERED FORM <br />