Laserfiche WebLink
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 form. <br /> File Original with DWR State of California DWR Use Only-Do Not Fig In <br /> Well Completion Report <br /> Page �_ of I Rererro rnshurL'on Pzmphhu Stale well NumbedSge• Num <br /> l Owner's Well Number L./-3 N3,• 00 5022 w <br /> Date Work Began -20-0 Dale Work nded 2 Latitude Lon fade <br /> Local Permit Agency s- Oa i, APN1111c' Bor <br /> Permit Number 05- 7-7 Permit Date <br /> Geologic Log Well Owner <br /> Odentatlon Vertical OHortzo al OAngIS SPedFi Name <br /> Drilling Method 4.r trilling Fluid Mailing dross j r� S J ��i^' •�^ 4T <br /> Depth horn Surface Description city ,� State._—Z <br /> Feet to Feet Describe material,man sae,color,etc <br /> c. /� � , Well Location <br /> LS 4x4,5^; �'�i Address r <br /> .bio city County S'icn OG�,g t..� <br /> Owe 4 t. . .LatitudeN Longitude __Yy <br /> ova. hurt Sac Dba. Mm. Sec <br /> Datum Decimal Let. DedmalLong. <br /> APIN Book Page Parcel <br /> Townshi - Ran Section <br /> h_ z Lo®atfan Sketch ACVVHY <br /> Sketdr mua be Clown by huW~ran Is tel 0New Well <br /> 0 MdiificationfRepair <br /> O Deepen <br /> y�0 Otter <br /> sV°y <br /> o�ow.pn�n.ana m.an.. <br /> wwm.•osaoso.Loc• <br /> Planned Uses <br /> _.._.._r•.---.-_.'_ ^� O Water Supply <br /> .� ❑Domestic ❑Public <br /> _ l .❑irrigation ❑Industrial <br /> O Cathodic Protection <br /> 0 Dewatering <br /> O meat Exchange <br /> O Injection <br /> P Monitoring <br /> O Remediation <br /> O Sparging <br /> O Test Well <br /> - '�'•°'^ `" O Vapor Extraction <br /> .wmaxm.«c.a,wa.a..Yksw r..a wwx�r.. +•. O Other <br /> 'MM do y0a6�.my lit.v6Jlllpi�plpyoY�ay. <br /> PIpYYp MpmxMkM <br /> ater`Level and relitof Com feted Well <br /> Depth to first water (Feet bei ce) <br /> Depth to Static <br /> Wa(er Leval (Feet Deasuned <br /> Total Depth of Bourg Feet Fstlmated Yield` Test Type <br /> Test Length (Hours):Total Drawdown_(Feet) <br /> Total Depth of Completed Wel Feel <br /> `Ma not resentative of a well's b term yield. <br /> Casings Annular Wilerial <br /> Depth from Bonhole T 'Materw wait ovande Scraen Sbt5" 'Dapth from <br /> Surface Dlamebr Type Thickness Diameter Tyle If Any -Surface Fill Dwcdption. <br /> Feet to.Feet Inches Inches .inches Inches Feat ro Feet <br /> Attachments Ceftifleation Statement `. <br /> ❑Geologic Log 1,the undersigned,oe that this ren�clt'd rate the best ofmy knowledge and belief <br /> ❑Well ConstrucU,n gram Name <br /> ❑Geophsical ? (s) CA <br /> SoitWetexl Analyses <br /> ❑ Othe Signed <br /> Awrhe wvomm.tlon gn.uur. csr ' w.ew wer Cano-ewr Date Si nod G57 LkenseNumben <br /> DWR IN REV,Ic008 IF ADDITIONAL SPACE IS NEEDED,USE NEn CONSECUTWELY NUMBERED FORM <br />