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0 0 <br /> 'rhe free Adobe Reader may be used to New and complete this form. However,soRware must be purchased to complete,save,and muse a saved forth. <br /> File Original with DWR State of California DWR Use Only–Do Not Fill In <br /> Well Completion Report <br /> Page_L of If q/ Relerio lnsarvdion PamMrn Slate Well Number/Site Number <br /> • Owner's Well Number [.'f f No.,,eepp95017 �� <br /> Dale Work Began 7 2 D o Date Wo Ended / Latsuae Lon nude <br /> Local Permit Agent '�tji j �ia. 9v/*e..�afG /i�w _ <br /> Permit Number 0-r7'J k6 permit ate —6b-0 9 APNlrRS/Other <br /> Geologic Log Well Owner <br /> OrientationVertical O Horizontal OAngle Specify Name ry <br /> Drilling Method og — Drilling Fluitl (���je•/ ti �, <br /> Depth from Surface Description Mailing Address 6d <br /> IAO <br /> Feet to Feet Describe material, min size,color,etc C' -State I <br /> 4i`c p Well'Locatlen .. <br /> Address <br /> f City County Six. <br /> _r Latitude N Longitude_ <br /> / Dau. Min Sec.::: OeR Min. Sec <br /> d„ Datum Decimal Let _ Decimal Long. <br /> dri fj rL APN Book Page Parcel <br /> Tovmehi Rang Section <br /> Location, ketch Activity <br /> kMM musty Jaen tr ha elpmlla md:t Qy Well <br /> \ Q ModificationlRepair <br /> O Deepen <br /> 0 Other <br /> ° <br /> troy <br /> -� peeaaxP«WeaMma[xab <br /> �,. � -,uwrosaooc roc <br /> —.-- — — — —� <br /> Planned Supp Uses <br /> ° Q Water Supply <br /> i ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> _.. t O Cathodic Protection <br /> Q Dewalenng <br /> 0 a w.... O Heat Exchange <br /> 9 Monitoring <br /> a O Remediation <br /> O Spangling <br /> O Test Well <br /> '"'�"""�''°"" �• O Vapor Extraction <br /> Luawxaaa=aeam«aaaxr ran a.aa.euray. <br /> : dw,x,xeaa wxm.aaP ua..emwr wwrx«.ww:. O Other <br /> Plc MseuaeaY <br /> #erLevei and'Yleld of IG"01efed ell :'-' <br /> Depth to firstwater F Slaw surface) <br /> Depth to Static <br /> - Water level (Feet is Measured <br /> Total Depth of Boring:. - Feet Fstirnated Yiekt• ) Test Type. <br /> Total Depth ofCanpleled Well Feet Test Length (HDIpS)Total Drawdown_(Feet) <br /> '. •Ma not senlative of a weti s 1 term 'ekl: <br /> Casings .' '.'eAY11ai;M5feial <br /> Depef from Borehole Y 'Material wan- h <br /> Outside ...:.Scaal sat Size Depth from <br /> Surface Diameter Type Thicknesa Dlsmeter, Type. IfAny surface Fill Description <br /> Feet to Feet latches (Inches) Indies ....Inches Feet to Feet- <br /> Attachment`s Certq)ofication Statement e <br /> ❑ Geologic Log I,the undersigned, is l tea rate tothe best of my knowledge end belief <br /> ❑Well Cons o 1--mm Name - <br /> em . «Cen+✓ex <br /> 17 Geophys og(s) CA <br /> ❑So Chemical Analyses v; <br /> 103 Signed r' <br /> esern U orafen 9f iWsta. caTu Sea wa.rwex COMaaor Da 5' ed C-57 License Number <br /> cwR iss REV,inoo6 IF ADDITION-.SPACE IS NEEDED,USE NEM CONSECUINELY NUMBERED FORM <br />