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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,saw:.and reuse a saved form. <br /> File Original with DWR State of Califomia DWR Use Only-Do Not Fill In <br /> Page Well Completion Report <br /> • <br /> Rebrb Instrucyon Pamphlet State Well Number/Site Number Owner's Well Number I,, - IL No. 009 031 <br /> Date Work Began /o Date Work Ended T Latitude Lon nude <br /> Local Permit Agencyu -V7-v" /I/- !LL <br /> Permit Number G •7 Permit Date 6"/l-0 9 APNlTRSIOther <br /> Geolo icLo nName ,, WellOwner <br /> Orientation (Vertical O Horizontal OAngle Specify � / ra '- s '-S <br /> DrillingMemod / L e Drilling FluidDepth"from Surface Description dress 7�T Y S- S. �• /•�• �a-.Feel to Feet Describe material. rain size.mbr.etc Stale'- 7•ogLb <br /> ( L. is tL- Well Location <br /> ro <br /> LG ..tea eC Address <br /> city . <br /> Latitude N Longitudey <br /> t t p C, Sy in. Mina S., DeR. Min 'Sec <br /> ���•� Datum Decimal Lat. _ Decimal Long. <br /> t�w.O Jr, APN Book Page _ Parcel . <br /> Township Ra 'e Section <br /> k _Sc.i cs t—lk =Location S10tth KcIvity <br /> kekn moat be drcwn 7med+1ter Mnia Med. O New Well <br /> gj a•� Nddn O ModifiationlRepair <br /> 0 Deepen <br /> O Other <br /> Destroy <br /> stiy <br /> Planned=Used <br /> —• O Water Supply: <br /> []Domestic []Public <br /> ❑Irrigation' ❑Industrial <br /> \\ \\ O Cathodic Protection <br /> \ O Dewatering <br /> ,\ O Heat Exchange. <br /> O Infection <br /> -., 1 Monitoring. <br /> �• _ �. O Remediation <br /> O merging <br /> \\ O Test Well <br /> aoau>ewalm so-,wawrawere.e.:wa.m.mw O Vapor Fxlraellan.. . <br /> ,Wgeic a,q•:.. fmap.ux aamwy ppva� O Gglef <br /> ... PIYaaMcaVeeaM <br /> ateF Levet an Yt 19W'�Com leted Well <br /> Depth to first water F elow surface) <br /> Depth to Static <br /> Water Level 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 /> "Me re reseniative ofawell'slongtermyleld. <br /> Casln"B , ` Annularlilateiiat <br /> Depth from BoreholeMateriel wall. outside Screen Slot Site Depth from <br /> .Surras Diameter Type Thickness Diameter TYPO IfAny Surhoe - Fill Description <br /> Fast 10 Fait Inches.... Inches Inches Inches Feet to Feet <br /> 'Attachments Certification'Statement <br /> ❑ <br /> Geologic Log 1,the undersigned,Do thalthi re P ��nd'. to. best my knowledge and belief <br /> ❑Well Construction Diag Name (1 1 <br /> ❑Geophysics!Lo 'F (At -0A <br /> ❑SofUWater mial Analyses ro Sues <br /> ❑Other Signed <br /> Adledrrgrk IMennedoe r It exbM.. GST Wn«W61CmVecer Da��C37 License Number <br /> DWR- EV.1M006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTNELY NUMBERED FORM <br />