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• • <br /> The tree Adobe Reader may be used to Hew and complete this form. However,software must be purchased to complete,save,and reuse a saved long. <br /> File Original with DWR State of California DWRUsa ON -Do Not FJI In <br /> Well Completion Report <br /> Page of Rotor to ms fion PomFnlef r��state Wan Number1506 Nummbm <br /> Number -1—�I <br /> Owner's Well Num ^yea No. o0 5020 ' IIN <br /> L_t � �� <br /> Date Work Began Date ork Ended 7 t Isritude Lonaltude <br /> Local Permit Ag.finu Ta=.9r.1� Co i £.�./Mo aa-t �u ( <br /> AP <br /> Permit Numberr$� Permit Date NrrRSlOther <br /> Geologic Log Well Owner <br /> Orientation edlcal O Horizontal OAngle Speciry 7Name o <br /> Drilling Method r..i'o � Drilling Fluid ddressDepth from Surface Descriptionity ,?.o State�i 9 �oFeet m Feat Desrrbe material, rain size,color,etc <br /> 53 I„ei Well Location <br /> Address <br /> City County -Saw 17 <br /> Latitude N Longitude w <br /> M J Deg. Min. Sac. ' '-Deo. MVI. -Sac <br /> c <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page - Parcel <br /> Township Ran Section <br /> a Location Sketch Activity <br /> Iskem,:munEsuan nand albrfamN rni ONew.Mill <br /> +� O Modil catioMdepair <br /> O Deepen <br /> O Other <br /> Destroy <br /> 1 w.,vEaaaicl.on- <br /> ... Planned Uses. <br /> O Water Supply <br /> ❑Domesbc ❑Public <br /> _ ❑Irrigation ❑Industrial <br /> ib O Cathodic Protection <br /> • (//�� O Dewatering <br /> ••� O Heat Exchange <br /> O Injection <br /> 16 Monitoring <br /> 1 <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> O Vapor Extraction <br /> leu»rn.werwitienalm caw I,a�ieaar,eub,p:bora. <br /> O Other <br /> - p.a..as=.m w,a eem <br /> aterLeveland Yield of Completed Well <br /> Depth to first water _(Feet below surface) <br /> Depth to Static <br /> Water Levei (Feet) .Date Measuretl <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 /> 'Mav not be re reseniative of a well's long term yield. <br /> Casings Annular Material <br /> Depth hon BoreholeWall outside screen SlotDepth from <br /> Surface Dlareder,. Type Material Thickness Diameter Type If Any Surface FIII Description <br /> Feet w Feet (inches) Inches . Inches Inches- Feet ro Feet <br /> Attachments ' -. -Certification Statement <br /> ❑Geologic Log NrNhe undersigned,certify th hisde ort i pj tSr,d aCCtQ the t of my knowledge and belief <br /> 13 Well Construction Diagram 20= <br /> cw�raa it„ti--t <br /> 13 Geophysical Log(s) �D �A ,1�� <br /> ❑SoiVWater Chemical Analyses S�Itetltaro <br /> ❑Other 7 car <br /> nnam agdigonel mr«mamr r n mom. wamr War CarMrLor Da S C-57 License Number <br /> DNR IM REV.12006 IF ADDITIONAL SPICE IS NEEDED.USE NEM CONSECUINELY NUMBERED FORM. <br />