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0 0 <br /> -The free Adobe Reader may be used to dew and complete this form. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR Slate of California DWR Use On -Do Not Fill In <br /> Well Completion Report <br /> Page of Rek/to Nstrwlon Pampnler State Wdl Number/Sde Number <br /> Owner's Well Number / e005030 <br /> Date Work Began a ate DWork Ended ��zr7 L o I / A Latitude Lon rude <br /> Local Permit Agency <br /> Permit Number--e2-2� 7 �� Permit _g6 /7-0 9 APNRRS/Other <br /> Geologic Log Well Owner <br /> Orientation JVerbCaI O Horizontal O . <br /> DASpecify— Name <br /> Drilling Method <br /> Fluid Mailing Address 269 f d L✓.'lam �, <br /> Depth from Surface Description <br /> Feel to Feat Describe material,grain size,.mlor,etc city 44-rfjL2h, State zip FOS ro <br /> w � � Weil Location <br /> Pt �..` .i i.nress d .ffia.. ..mss S G-ha�F <br /> `.....4 �,i.e <br /> City unly rsE_,jms�x s.... <br /> 2, a ✓c L C.cv Latitude N Longftude__----N <br /> (EKE lfivl✓C Deo- No. sec. Deo: Min. soc. <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page Pamel <br /> 'r <br /> Township Ra Section <br /> - i - Location Sketch Activity <br /> 0New Well <br /> Motlitien Repair O Deepen <br /> O Other <br /> •.Destroya«.aw...a <br /> ,aderoaaoOhc Loc <br /> Planned()ties ' <br /> ------^.. _ 0 Water Supply <br /> ❑Domestic ❑Public <br /> X\ ❑Imgation ❑Industrial. <br /> i 0 Catholic Protection <br /> 0 Dewatering <br /> T' 0 Heat Exchange <br /> ° 0 Injection <br /> 0 Monitoring <br /> 1 0 Remediation <br /> 0 SPafging <br /> 0 Test Well <br /> a,.,.n.d.. - —• -0 Vapor Extraction <br /> a,.eMeae.u;,'e.asenr a..aaena.m.D .+f— 0Other <br /> ,. ,Iwn.MCNEafl,a maP IwaeJbalpgrrYnwary <br /> atef Level and V161d:0 Coin IetedVell <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 Vi FeetTest Length (Hous)Total Dmwdown_(Feet) <br /> -May not be representative of a well's I term Id. <br /> Casings A imilae Mateirial <br /> Depth from SttrohoN TyW mat" wall.. Outside Screen-. Slot Size Depth from <br /> Surface Natnrter- Thklmeea DlaMSW Type HAny surface Fill Descrfpdon <br /> Feet. to Feel Indicts) Inches Inches Inches ..Feet ro:.Feet <br /> Attachintahts. . -. 'Certification Statethent`.... <br /> I]Goo Log.. ,1,the undersigned,ce ' halth re p leande tohe best of my'knowledge:and belief <br /> f Oil- <br /> ❑Well Corlstru Diagram Name YV <br /> ❑Geoph I Log(s) aCA <br /> ❑S fCttemleal Ahalyses a y o. <br /> Signed -_ <br /> A9Wia aeoau xhEear Ilxenate wYx watl Da sin C-57 License Number <br /> DWR tae REV.112006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />