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'The free Adobe Reader may he used to New and complete this form. Hoverer.solMare must be purchased b cwnpele,care,and reuse a saved form. <br /> File Original with DWR State of California <br /> DWR DSBD -Do Not FitN <br /> Page of —�-y� Well Completion Report E <br /> Owners Well Number (vl -L- No 000r"b95458 <br /> 1�--a�mte�Wea�Numbed5ite Number <br /> Dale Work Be <br /> gan 1. Date W Enrlpd 23 20'09 Lu 1 �1 I I I r W <br /> Local Permit Agency A oL1�a u4 V, C <br /> Permit Number SQ 057777 Permit Date zd APNrrRS/gher ` <br /> GeHo !c al Well Owner ' <br /> Orientation Vertical k(,',C�i�Hodzonlal OAngle speesy Name <br /> OriBing Mathed W 51'eM1 " Drilling Fluid 1T� I <br /> Depth from Surface Description Mailing Address'_22 T-42 . "TCAD & lok Q0.• _ 4 <br /> Feel Is Feet Desrnbematerial rail size,Color,etc cityIIr1a, hNG!fL Stale ' ]- 953 <br /> Well Location <br /> Address�' A.��� <br /> City a e-� County SOLN dA VI <br /> J E <br /> 0 VC C.IJI-N fLt Latitude NLongihMe_ If <br /> Amn. IM Sec �(,., Deo. Ms, a.. W <br /> > t d <br /> Datum—�—Dectimal Lal.37r7'TV Dedmal Lon-(21.WZ <br /> APNBook 3_-JPage '37 Parcel 00 �d <br /> W 1 Vy)--Lt, ✓j/(( Towrlshi —Ranoe Section <br /> Location Sketch Aotivlt <br /> v hd sn.ml a.atasawn nano allerbrmh New Well <br /> North O ModifrcationlRepair <br /> O Deepen <br /> W O Other <br /> 141W Voesboy <br /> Planned Uses I <br /> O Water Supply <br /> ❑Domestic ❑Pudk <br /> 3' xT <br /> Cligation ❑Industrial <br /> I Cathodic Protection <br /> Ir�JI O Dewatering <br /> O Heal Exchange <br /> O Injection <br /> _ O Monitoring <br /> O Remediation <br /> C' ( Sou h O sremg <br /> O TeTesl Well <br /> AAeaeber eerie Javaa e/wa sa.A.m.wrsiss rwwaa O Vapor Extraction <br /> O Other <br /> Water Level and Yield of Completed Well <br /> _ Depth to first water (Feel below surface) <br /> _ Depth to Stadia pi - <br /> Water Level f r Ll (Feet) i Date Measured 7/Z)7 <br /> /09 f <br /> Total Depth of Boring (7 Feet Estimated Yield (GPM) ,Test Type <br /> Total Depth of Completed Well N Feel Test Length (Hous)Total Drawdown_(Feet) <br /> i'Maynolbermoresenladve of a well's lono term yield. <br /> Casings Annular Material <br /> Depth fromaoreMaterial hole Type MatWall Outside Screen Slot Size Depth from <br /> Surface Diameter Thickness Diameter Type If Any Surface FIII Description <br /> Feel b Feel Inches - Inches inches Indus Feat Is Fast <br /> k <br /> Attachments Certification Statement <br /> ❑Geologic Log L the andarNgned,ced"dy that this re�prt is oorppl91a end accurate 10 the best of my knowledge and belief <br /> ❑Well Gon rbuction Diagram Name Pf'aFNmO-C r S f /M J/'l/f•1•'U YI�+1 : <br /> ❑Geophysical Log(s) Z3(n 5 W'K-W 4A 13V-. i :S f-V R-I^ '' A CI`J�6 <br /> ❑SoiUWaterchemicalAnalyses rasa n a� <br /> 13 Other Signed C o�M�o� (150inS/R-ee.yy,car sws wxwd°( 03638/ <br /> AIMdI INomxean rneml:. csr lAmmeewalerwn rmmm Date Sinned C-57 Dcanse Number <br /> DNR IM Rev.1caee IFADmrIOINI.SPACE IS NEEDED,USE HFM CONSECUT YNUA®EREO FORM III! <br /> i I <br /> J <br />