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I <br /> The free Adobe Reader may be used:to New and complete this form Hmv mr,soaxam mus,be purchased io oorflple a,save,and reuse a saved form. <br /> File Original wish DWR Stale of California fNYR Use -Do Not Fal In <br /> Page of 1 Well Completion Report <br /> ReAorm6am.�'an Pa.svvet Stale Waa Number/Sim Number <br /> Dale W Well Number W" No. 0095489 <br /> Dale Wolk Began 2- 200 -t N w <br /> e9 Dale W Enda 23 d Lalxuaa .. L� ) <br /> Local Permit Agan C N 1/ E .. <br /> Pemdl Number 5 Permit Dale L(J 9 APWVRa/Oihor k <br /> Geologic LouWell Owner <br /> Orientation Ventral O Horizontal OAngfe spetify Name Q.til CQ A (� <br /> Doing Methoe 0 rn1 5 Drilling Fluid �� MaNi Address ZZ Z Gl(J f—m4 17 e- <br /> Depth from Surface Description <br /> Feet le Fee, Describe malarial reln s¢e'calar etc Cil %?4 Stale 1/53,93 <br /> ,�\ Well LocationWfA <br /> A4 W:3 Address 59S r f(f44 'SrtPLX- - 1 <br /> City Tr1:l C r C CountyAt <br /> SLia.k�dAa'Il� <br /> lA VIS Latitude N'..Longhude t <br /> s.� <br /> Datum Decimal Lal.37r.71FO Decimal Long.l ZlTr Y'1�7 <br /> APN Book'Z33 Page37': Parcel f�0 Jiy7- <br /> -L1, Township Ran Secaon <br /> Location Sketch Activit J <br /> QSee101 mal he ererna h+M aMbmlu ONew Wall <br /> Nanh O Modification/Repair <br /> PELF TZ O Deepen <br /> S OOther <br /> Destroy <br /> o.oa.vma.sae m.rr. <br /> .. wrroeowraccoc <br /> Planned Uses <br /> O Water Supply <br /> H ❑Domeslic ❑Public <br /> 3 3 Fes', w ❑Irrigation ❑industrial <br /> 'L(I O Cathodic Prole hon ) <br /> l O Dewatering 1 <br /> 1` <br /> mw-3 O Heat Exchange <br /> 17 0In)ection <br /> O Monitoring <br /> O Remediation <br /> . O Spangling <br /> South O Test Well IV <br /> ru.e aeaaxe auwmwar,.�e.sire..r..,.. O Vapor Extraction <br /> a ..r.arw�.n+w.aesm�+rawaaaer.,y. O Other <br /> - VIxu M.mni..�tl <br /> Water Level and Yield of Completed Well <br /> Depth to that water (Feet below surface) tt <br /> Depth to Static 2 I <br /> Water Level 01!-?-- <br /> Total <br /> Z (Feet) 1 Date Measured 7 �� i <br /> Total Depth of Boring Feet Estimated Yield (GPM)'Test Type <br /> a, Test Length (Hours)Total Drawdown_(Feel) <br /> Total Depth of Completed Well /I/ Fact 'Ma not be representative of a wag's to Ielm M. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Scrssn Slot Size Depth from <br /> Surface Diameter type' Material Thickness Diameter Type If Any Surface Fill Description <br /> Feel a Feel (inches) Inchesfinches) Inches Feel b Feet <br /> i <br /> i <br /> Attachments Certification Statement <br /> ❑Geologic log - - I,the uMej�Igneq Fert�ly that t report Is fWlete and accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram Name_,.(.P"t-t_C1 S 1cNrwn..wn fM�D !/'0�.l.� �L,L �^ <br /> ❑Geophysical Log($) 2 s F W0.i1n Q✓l f OGF—I P Com/ S Zdl <br /> ❑Sol9Water Chemical AnalysesA re ohiSwa a <br /> E3 Other slgnedQ �{� ` wW�SlPr2elsi'f -i -F(o't 036-507 <br /> AIWT asmmrelsxanrm naeriw. csrl.Ioenaw wmerweeconvmor <br /> Data Signed GST License Number <br /> own 168 REV.Ir'008 IFA MIO SPAEMMEDED.USEN WNSEGmVEIYmaMeEREDF ' <br /> v <br /> it <br />