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*The free Adobe Reader may be usedlo vlewaM complete this tonin However.solhrdre mull be (I a saved <br /> purchased to mrripete,save,and reuse fpm, <br /> File Original with DWR - Slate of California <br /> OWR Use -Do Not Fi0ln <br /> Page_� or ( Well Completion Report <br /> Owner's Well Number I�—¢ AwO. MrrA54 Perry/Y.f $Ia16.Wefi Number�Sita Nwnr <br /> No. 0954 0 <br /> Date Work Began L 2 OOR Date w En d L 2009 w <br /> Local Permit Agency L(!`I,tt/r Lalxude L <br /> -- <br /> Pe nMt Number 4ROS7777 Pe"it Date / q MNrrasroUler <br /> Geologic Log Well nor <br /> odentatlo0fdca0 Ho'zonlal OAName Method 6vC3kz� DlBng Rod N <br /> Depth from Surface Descdpgon Mailing Address ZZ$(pZ f4,1j7Gt ,1e <br /> Feet a Feel. Desatematelot aba'es color,etc Cil W r% C,,Ft' . 53� <br /> Well Location <br /> Address 9 S <br /> /'2t1n0 1/!`YlGG(SM city P-K „ county 3 fat a/Zl <br /> _ Latitude N LongitudeIF ____yy <br /> Dec. Lon sec Doe. Mh a.. <br /> C a Dalum Doctrnal Let.3/ 7T[J Decimal Long,irZI.W( <br /> APN Book Z 3 3 Page_ J 7 Parcel 3 <br /> W! C y'(j Townsh -Ron2o <br /> Section <br /> Location SketchTD <br /> Activl <br /> -� SkekA nantee er.an nand ellerbrm6New Well <br /> NomModiftcation/Repalr <br /> SIAr (V(6(f- 0Otheropea <br /> .. li O Ogren <br /> �� eslroy <br /> .�n��..M..Planned Usesater SupplyDomestic ❑PublicIrrigation ❑industrial <br /> athodic Protedion ewateringeal ExchangelecbonLi onitoringemediationt+� Pmgingest Well..u.•da�nu.s.,e..r.aeo,,,.-mn+aapor Extractionther <br /> PYp.b.aum rtl <br /> Water Level and Yield of Completed Well <br /> Depth to final water ' (Feel below surface) i <br /> Depth to Static <br /> Water Levelid(Feet) Date Measured;r�i 9 <br /> Total Depth of BoringZ Feal Estimated Yield' ^/ (GPM) Test Type I <br /> Total Depth of Completed Well N Feet Test Length (Flours)Total Drowdwm_(Feet) <br /> 'May not be re resentativa of a Well's long term yield- <br /> Casings <br /> ield.Casin s Annular Material <br /> Depth from Borehole Wall Oubdde Screen Vellum Depth from I <br /> Surface Diameter Type Material Thickness Diameter Type If Any Surface Fill Description <br /> Feel m Feel Inches Inches) fli,ichesl Feel Ie Fact <br /> 11� <br /> f <br /> Attachments Certlflcatlon Statement <br /> ❑Geologic Lop i,the and Igned that thlsreport Is a4m lele and accurate to the best of my knowledge and befief <br /> ❑Well Construction Diagram Name hQ-(A Srl o7,FMv nJ QLNAAII h^ <br /> ❑Geophysical Logs) 23fo5 ��I�.VKm A f s. fun may X5205 <br /> ❑❑SOther alar Chemical Analyses Signed _ iSiLlil city7( _q-foq �(p 3(C 3� <br /> Allan ads i aaemM. '- csr ucavea weerwmcolurana. /TeC pale Si nod- C57 License Number l <br /> DNR rIB REV.Value IF A)DITIDNAt SPACE 1a NEEDED,USE NExT COHSEfArrNELYNUMeERED FORM F <br /> I <br /> ' I <br /> I <br />