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i w <br /> 'The free Adobe Reader may be used to New and complete this form. However,sdtware must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Only-Do NO Fill In <br /> Page of 1 Well Completion Report <br /> � <br /> — R Mrfo Instnctim Pamphlet State Well NumbedSite Number <br /> Owners Wel !-Number_ r v / � No. eOO95032 <br /> • Date Work Began :Z-LO - 7 Date Work Ended - O-o Latitude Lon kude <br /> Local Permit Agenq <br /> Pend Number 92.�. Permit Date /2-o�J ,(, APWfRS/cher <br /> Geologic Log Well Owner <br /> Orientation VVertical O Horizontal OAngla Specify Name_ s O <br /> Drilling Method (lc f..rc � Drilling Fluid <br /> Depth from Surface Description Mailing Address 209 Y.S �. lam.°�iwi_.<Fir_ <br /> Feet to Feet Describe material,grain size,color,etc G State�i grU rpl6 <br /> tv /l Well Location <br /> Address 312 1 /40,,� <br /> �o City County _ <br /> a - Latitude N'Longnude <br /> Deo. Min. Sec' ..Dee. Min. Sec <br /> Datum Decimal Lat. -. Decimal Long. <br /> e APN Book Page Parcel <br /> Township Ran- Section <br /> LcI ationW OO Acthirity <br /> moat bahwn haM aMrfamis a. O New':Well <br /> O Modificationu Repair <br /> O Deepen <br /> OOther <br /> •Destroy... <br /> o.rml pomrs:.ana n,wn.a <br /> PlamRed Uses <br /> O water Supply <br /> :❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> "`. O Dewalenng: <br /> O Heat Exchange <br /> 0 Injection <br /> i ` Monitoring <br /> °% O Remediation <br /> °e O Spatging <br /> .... O Test Well <br /> O Vapor.Extraction <br /> mM,m a«f maa.m.p U..xaMr ate.x.sa...x. O Other <br /> - Plxere MataeNxmx <br /> ifeF•LeYahana Yfela-of r;nfii Tef�d. oll :. <br /> Depth to fist water (�etelow surface) <br /> '. Depth to Static gtjj <br /> Water Level Dale Measured <br /> Total Depth of Boring Feet Estimated Yeld a (GPM) Test Type <br /> Total Depth ofComplelee Feet Test (Howl).Total Drawdown_(Feet) <br /> Va-Y not tie representative of a were long term yield. <br /> ' .Caein`s Ann0larMatartal <br /> Depth from El"hule Wall. Oubtda Screen S m <br /> Surface ots"Idt"' Type Materiel Thkdmess Diameter NAny Surface Fill Desedption <br /> Feet w Fed Inches I Inches r Feet m Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log. . 1,t a undersigned, th tthis is plele anti rat athe last of my knowledge and b Hef <br /> ❑Well Construction Diagram C <br /> ❑Geophysical Log(s) morn (,t, A.. .�c( �,i <br /> ❑Soil/Water Chemical Analyses a C4" OK., <br /> ❑Dow Signed <br /> A chadalbntl.IMamaean ream. c wawwa Cmbacmr Date STL - Number <br /> VMI IN REV.1rM IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSE=IVELY NUMBERED FORM <br />