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'The free Adobe Reader may be used to view and compile this form. Hummer,software must be purchased to complele,save,and reuse a saved form <br /> File Original with DWR Slate of California DWR Use On -Do Not Fa In <br /> Page of _L Well Completion Report <br /> RwroauxcmvhParaeear Slate well NumberlSne Number <br /> Ownets Well Number W' No. eOD 5 85 <br /> Dale Wofk Began 7 23 Dale Wo ntd Z d Leeludo Lo dud <br /> gan e <br /> Local Permit ArVl - A V <br /> Permit Number S Permit Dale 9 WWIRSIOIher <br /> Geologic Loa Well Owrier <br /> Orientation V�ryc�I QHarizontal OAngle Specify Nsme YS OL <br /> IkDIIg MaIMO II/I/NS?�il't't Dmm�g Flukl r N.d GVNnA <br /> Depth from Surface : Description Mating AdtlmssZZ y c <br /> Feel to Feel Describe material grain slz0 color etc Cil 6(/ r SleiO V <br /> Well Location <br /> IX (A-� MW Address Fjo SiI <br /> City CACounty OMu�t <br /> 7 <br /> fl/ SLNLatitude N',Longitude <br /> Doo.- AYn sec. 1,, Deo. Mb. Sec. <br /> G ( O () <br /> Dal— : Decimal Lat.3• cI O Dedman Long. (Z <br /> APN Book -3 3 Page :37 _ Parcel0 <br /> frj� Townshi Ran a Section <br /> .. Location Sketch Activit <br /> d SRelU nasi bedamhhhtlaaafaenb kd. QNew Well <br /> O ModiSratiorgRepalr <br /> O Deepen <br /> $(d, CQ OOther <br /> kDestmy <br /> ' oovx.ov:a...wm..r <br /> - ,. vw,wxa,aceroc <br /> - a p Planned Uses j <br /> '9R O Water Supply <br /> ❑Domestic ❑Public 1 <br /> ❑Irrigation, ❑Industdal <br /> O Cathodic Protection <br /> O Dewatering <br /> �- O Heal Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> OSparging <br /> O Test Well <br /> South <br /> . scarab>amaawv.uaenva .P.has. O Vapor Extraction <br /> n�ecea.wn.arp v«.esraPye rree....r. O other <br /> Water Level and Yield of Completed Well <br /> -- Depth to first water (Feet below sudace) <br /> Depth to Stage <br /> Water Level (6 (Feet) Date Measured 7123ij� <br /> Total Depth of Boring 2, Feel Estimated Yield' Al I ft (GPM) Test Type <br /> Total Depth of Completed Well M Feet Test Length A (Hours)Total Drawdown_(Feel) <br /> iI I'May not be representative of a well's lom Tenn yield, <br /> s <br /> Casings Annular Material <br /> Depth from Borehole - Wall Outside Screen Slol Size Depth from <br /> Surface Diameter type .MaterialWall <br /> Diameter Typo If Any Surface FIII Description <br /> Feet I0 Feel frndhes - Wes Inches Inches Feel to Feel <br /> I <br /> Attachments CelllOcalion Statement <br /> ❑Geologic Log - 1,the undettrigned.cer "I'm Vmpla-and ac <br /> urate to the best of my knowledge and betlef <br /> [3 Well Construction Diagram N <br /> 17 Ksec <br /> ❑Geophysical Log(a) 23G 6 S h CkfT✓L <br /> CA R5206 <br /> ❑Solt/Water Chemical Analyses - _ car sale m <br /> ❑Other <br /> signetlU 11�W11/6SlpieC;silA. l7 Z`11�9 G363E7 <br /> ;am,n yaeWlr. urhr as worm wacanuamr Date Signed C57 License Number <br /> MR IN REV.IfI00(I IFADDITO SPACE IS NEEDED,USE NF%r CONSECUnVD.Y WU REI)FoRM <br />