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0 i <br /> 'The free Adobe Reader may be used to view and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DM Use Only-Do Not FYI In <br /> Well Completion Report <br /> Page_ of ( Rererro Instrucp'ar Pamp*t TStat-WeM Numbed6fte Number <br /> Owner's Well Number ki LZ No./n-D-09 028 1 1 1 1 1 1 1 n• ��LDale Work Began 7✓Zo o Date Work Ended �rL Latitude Lon lode <br /> Local Permit Agency a^ rT L •.- /c•'G <br /> Pend Number O;�?7�iS Permit Date �I APWfRSl— <br /> Geologic Log Well Uwrler <br /> Orientation `Vertical O Horizontal OAngle Spealy .Name Sze it,O. " <br /> Drilling Method Drilling Fluid .Melling Add w 1- <br /> Depth from Surface Description �. State C-�7i 71986o <br /> Fad to Feet Describe material grain:size color,etc <br /> A.0 Wall Location <br /> Address <br /> ..City /a.� CountyZ.c. 0T0 ft* <br /> f LatitudeN Longitude <br /> ...r Dep. Min. Seg. 060. Mtn. Sac <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page _ Parcel <br /> '✓• Ca Township Ran"e Section <br /> Location S ' Activity <br /> _ SkatM muabe ocean l6rr4mie O New Well <br /> ' O Modification/Repair <br /> . - O Deepen <br /> O Other <br /> Destroy <br /> .P ovale,wea.�Na my.n+ <br /> ..y. uMet'GEOLOGIGLOG' <br /> Planned Uses <br /> _.._.._,..,._..___- ` OWater Supply. <br /> 1 ❑Domestic ❑Public <br /> ry i <br /> 01mgation ❑Industrial <br /> IIfLt��-gy�Nt ° O Cathodic Protection <br /> Allmatering <br /> , r" O Heat Exchange <br /> O He e g <br /> O Injection <br /> t Monitoring <br /> O Remediation <br /> k^ O Sparging <br /> O Test Well <br /> e�.am.waeme.aena..a.rian ia.es wa-n..Mm O Vapor Extraction <br /> „.,..erre wr+n.m.P.u..awrinY l•Pvya.®vr O Other <br /> Plr�[a ctV�ISMcam <br /> Water 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 Feet Estimated Yield (GPM) Test Type <br /> Total Depth of Completed Well Feet Test Length - (Hours)Total Drawdown_(Feet) <br /> 'Ma not be re resentatiw Die well's long term yield... <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Sin Depth from <br /> Surface Diameter Type Material ThreWesa Diameter Type IfAny Surfaea Fill Description <br /> Fed to Feel Inches Inches Inches Inches Feet w Feel <br /> Attachments Certification Statement <br /> 11 Geologic Log 1.the undersigned,oerti at his r I m ape antl. to to a best of my knowledge and belief <br /> ❑Well Construction Diagram Name (L V� `n <br /> P. <br /> orcorpcm .n re <br /> ❑Geophysical Log(s) <br /> ❑Soil/Water Chemical Analyses ,Sime .� <br /> ❑Other Signed <br /> Alam mayoral wkmr,eon y It wsm_ bsT nava Wetet wen Cmyectar Dal SI d G57 License Number <br /> DWR IN REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEM CONSECUTIVELY NUMBERED FORM <br />