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0 0 <br /> The free Adobe Reader may be used to New and complete this toren. However,sollware must be Pu1hMd to complete,saw,and reuse a saved form. <br /> File Original with DWR State of California DAM Use Onl —Do Not HN In <br /> j Well Completion Report <br /> Page of Rehirminmprtioa Pempn.t ��—State Well NumtM91791e Numlter� _ <br /> Owner's Well Number f L V-Z-g Z No. 0050 <br /> Date Work Began l0'p Date W rk Ended Latitude Lon a <br /> Local Permit Agenq ��.. <br /> APWrRS/OUter <br /> Petmd Number Permit Dale <br /> Geologic LWell Own$r <br /> OrientationVertical O Honzom I OArgle Sptsary Name <br /> DnNNng Method /YrSS�'� DrNling Flud 3,G9flS '.S. �� ArJy�fan,� <br /> Mailing address <br /> Depth from Surface Description State <br /> Feet m Feel Describe material, rain size,tabr,etc <br /> (r !Z w Well Location <br /> Address <br /> City County er.�(� <br /> Latitude ___ N Longitude <br /> C — ON. Min. eac. —5w- <br /> 14C <br /> em MM. Sx <br /> Datum Decimal Lat. Decimal Long. <br /> APN Book Page -Parcel <br /> Township a Section <br /> - .:'.In Activity <br /> .......:: ....^..w ...,. i. tear O New Well <br /> IL O Modihcation/Repair <br /> 0Deepen <br /> ,r Other— <br /> troy <br /> `r pamd.�xtl maNaY <br /> � xMx'GEOLOGIC LOG' <br /> .... _ n <br /> Planned Uses <br /> O Water Supply <br /> C]Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> � O Cathodic Protection <br /> IL����..gy�In1I O Dewatering <br /> O Heat.Exchange <br /> ' Olnjection <br /> Monitoring <br /> t %'x O Remediation <br /> 0Spargin <br /> O Test Well <br /> elavx.x erxme murce a.er exn mes,uaaes.� _ O Vapor Extraction <br /> mwR,x�.b.mm.mw.u..wmwutmwNrl.e-.r OOther <br /> F. wears ria wen xe.. <br /> Water Level and Yleld dVaffilipliultedwell <br /> ' Depth to first water (Feet below urfrfce) <br /> Depth to Static <br /> Water Level (Feet) Da asured <br /> Total Depth of Boring Feet Estimated YieldTest Type <br /> Total Depen of Completed Well Feet Test Length (Hours)Total Drawdown_(Feet) <br /> *May not be re entative of a well's.long term yield. <br /> Casings Annular Material <br /> Depth from Borehole al Will Outside Screen slot size Depth hem <br /> Surface Diameter Type Material Thickness Diameter Type Surface Fill Description. <br /> Feel to Feel Inches Inches Inches Inches Feet to Feet <br /> chments Certification Statement <br /> ❑ Geologic Log I;.the undersigned,certify in his ort is M d accural. e tofmy knowledge and belief <br /> ❑Well Construction D' m 'Name f) <br /> Pe FmiaGarp lion <br /> ❑ Geophysical Lo 0 - -4 CA �[� 7 - <br /> ❑ SoiVWater. - ical Analyses Signed I�GIB2 city <br /> a sin <br /> ❑ Ogler <br /> Adam nmrmeila,seen , GS]lxemedWWrN'el Contrac0or Dale:Sf C57 License Number <br /> DWR in REV.142006 IF ADDITIONAL SPACE ISNEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />