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0 0 <br /> 'The Iree Adobe Reader my be used to view and canplete this lam. However,software must be purchased to complete,save,and reuse a saved form. <br /> File Original with DWR State of California DWR Use Ohl —Do Not Fill In <br /> Well Completion Report <br /> Page _ of I Remrrolnsmx»on Pampnlel State Well NumbedSite Number <br /> iOwner's Well Number No. e0095019 �jW <br /> Date Work Began i O Date Work Ended Z d 39 Latflude L dude <br /> Local Permit Agency O �^ l h <br /> AFWTRS/Other <br /> Permit Number Permit Date 6�&�42 0104W <br /> Geologic Log Well Owner <br /> Orientationrtical ONoraontal OAngle Specify NamedSAT / <br /> DrilingMettwd Ddning Fluid Mailing Address L09/l S Ly '��-/-•Fs-�'.re <br /> Depth from Surface Descriptions r State4X 7i O <br /> Feet to Feet Desceibe matedal. - n slm,color.etc City <br /> Well Location <br /> r Address deve/ 14 <br /> 1f City.. c County -, lzail <br /> - <br /> Latitude N LongitudeW <br /> Dep. Min. Sec. oep. Mn. Sec <br /> Datum Decimal Let: `--Decimal Long. <br /> APN Book Page Parcel <br /> crt Township Ra a Section- <br /> Location 51kefch divity <br /> I:etM muetl»drrm nsrW we.rfamM ted: O New Well <br /> O Modification/Repair <br /> nlRepair <br /> \ O Deepen <br /> 1-4 - O Omer <br /> oDeswatroyiau�.emem.ep. <br /> v. wwr,Eaaxc we <br /> Plinoeii Uses <br /> Water Supply <br /> ` ❑Domesti ❑Public <br /> ❑Irrigation0 ❑Industrial <br /> m \ S \ O Cathodic Protection <br /> �O Dewatering <br /> O Heat Exchange <br /> Q Injection <br /> 4V Monitoring <br /> 9 a _ O Remediation <br /> 1 R q O Spatging <br /> — - '.O Test Well <br /> O Vapor Extraction <br /> euM4aM1.wkeerYrcealvwRRanNM.'Wiei.95 rwm. - <br /> Me,.ea'q.rueramrawmwrProry OlDther <br /> PMwMmr6rgmm <br /> at17:Metand Yfeld dMotnipleitatl <br /> Depth to first water (Feet bweunace) <br /> Depth to Static <br /> Waler Level. (Feet) aasuled <br /> Total Depth of Bering Feel Estimated Yield• M). Test Type <br /> Total Depth of Completed Well Feet Test Length Hours)Total Drawdomm,_(Feet) <br /> •M6—representative of a well's eld <br /> Catalogs AnnSlar.Matertel <br /> Depth from Borehole i Material wall outside: scream Sbt3W Depth from <br /> surface Dwnptw Y� Thicknese Diameters Type MAny surface Fill Description. <br /> Feel.'a, Fent Induce Inches I Inches Feet to Feet <br /> - Attachments Certification Statement ' <br /> ❑Geologic Log :.1.the undersigned,certify tN n r�acDUfe st of knowledge and belief <br /> ❑Well Construction DI nn 'Name <br /> ❑Geophysical a 1C I <br /> ❑SbIUW tremkal Anatyset: car 9 �"1e !' a <br /> ❑ Signed J <br /> AdeN YXannebnramdas. c Wak"wr Comrsaa :.Data Sl reed C-57 License Number. <br /> owwree hE Intioe IF ADDITIONALSPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />