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0 0 <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 torte. <br /> File Original with DWR Stale of California DWR Use On –Do Not Fit In <br /> Well Completion Report <br /> Page of t Rwerto rnm roam PamWn $late Wag N imbedSite Number <br /> • Owner's Well Number T2, No. 00 5018 Q N W <br /> Date Work Began Date Work Ended Z, Latitude Lan "lode <br /> Local Pennit Agency d.+ J ry lP �I46v e �� <br /> Permit Number Permit Date !z-8! APNIIK Olhx <br /> Geologic Log Well"Owner <br /> Orientation erfical 0Horizontal OAngle Specify Name G i rd 4 & <br /> [)filling Method Drilling Fluid Mailing Address 1(��73 ^ �K' <br /> Depth from Surface Description Slate i <br /> Feet to Feet Describe material, rain sae,color; Icily, <br /> r fr WeII Location <br /> Address 's <br /> ( City County <br /> t Latitude NLongitude <br /> Gil - Did. Mr. sac. Deo. Min :Sac <br /> Datum Decimal Let. Decimal Long. <br /> AVN Book Page - Parcel <br /> Township Ran oe Sedjon– <br /> Location Sketch Activity <br /> ,. �.. . <.� ketol,mustmd nand~mml is Q New Well <br /> O ModificationlRepair <br /> O Deepen <br /> O Other <br /> �}Destroy <br /> ..p aie.r cEaooickar : <br /> ` Planned Uses <br /> O Water Supply <br /> i ❑Domesfic El Public <br /> •� ❑Irrigation ❑Industrial <br /> ty O Cathodic Protection <br /> —� O Dewatering <br /> �` • O Heat Exchange <br /> ............ �.e OInjection <br /> o i <br /> c �'� ® Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> uuawe ora..am.awaaeawii raa wa.,nedpw.a�A O Vapor Eldradion <br /> mws,.oc aye atidf.mq u.w�a wa*'^ter. O Other <br /> elraMasvAwrlmm leha <br /> 1111f <br /> ate[Level and Yield of Completed Well <br /> Depth to first water (Fe ow surface) <br /> Depth to Static <br /> Water Level (Feet le Measured <br /> Total.Depth of Boring Feet Estimated Yield ) Test Type <br /> Total Depth of Completed Well Feet Test Length (Hours) Total Drawdown_(Feet) <br /> *May not be ran ative of a well's long term yield, <br /> Casings Annular Material <br /> Depth from BoreholeT Mater Wall Outside Screen slot Size Depth from <br /> Surface Diameter ypa Thickness DiameW. Type. If Any Surface Fill Description <br /> Feel m Feet Inches Orches Inches Innes Feet to Feel. <br /> Attachments CertiNcationStatement <br /> ❑ Geologic Log I,the undersigned,certify' t e m end acw�fk b t of my knowledge and be <br /> of <br /> ❑Well Consbuctio agram Name <br /> ❑Geophysi og(s) °r CA <br /> ❑ S r Chemical Analyses - CRY. <br /> stsa <br /> er O 71:3Sined <br /> Am addtiu,m information x K"ft. C-5 <br /> License Number. . <br /> DWR IN REV.14006 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />