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'The free Adobe Reader maybe used to view and complete this foml. Hveever.sof Bare must be purchased to complete,save,and reuse a saved Form. <br /> File Original with DWR Stale of California DWR Use On -Do Not Fill In <br /> Well Completion Report <br /> Pageof Relev to Mammas P.,~ <br /> Owners Well Number _ No. e0095487 slate Well Number/Sae Number - <br /> DateWorke an a7 2 2 0') Date ork nded7 2 2lId9 <br /> Began Latitude Let <br /> IWa <br /> Local Permit Agan��]yr r ta <br /> Permit Number SR057777 Penult Date 2009 APNlFR51171her <br /> Geologic Log Well Owner <br /> Orientation edfcal 0Horizonlal OAngle Specify Name "Mf CU 1.l <br /> Draene Meltwd NO IvlvSlue � Dnleg FMld A11A Mali ng Address 2L8(nL M 7UOItA 144 r <br /> Depth from Surface Description Cit 7Aip rls eu cl.ro 7; _S3$ <br /> Feel W Feel Describe material, In Size color, tc e --- <br /> Well Location <br /> W_ Address Eq F <br /> City TvsA�puS_ CA County SAM as <br /> r`QMg dil Latitude ___ N Longitude__�v <br /> DmM'v� SmDee. Mm. e <br /> &ttiC M dh/1't Datum-yDedmal LaLU NO Decimal Long.l�, <br /> APN Book ZZ Page 3 7 Parcel a ! <br /> W 't't fs Tovmshl -Range Section <br /> "LocationSketchActivitC, ONewWell <br /> O Moc incationiRepair <br /> O Deepen <br /> 0Other <br /> Destmy <br /> est <br /> .erroaetoncrm- <br /> Planned Uses <br /> f{ O Water Supply <br /> ❑Domestic ❑Public <br /> Il i ❑Ingation ❑Indusldal <br /> O Cathodic Protection <br /> O Dewatering <br /> O Heal Exchange <br /> O Injection <br /> O Monitoring <br /> O Remediation <br /> r O Sparging <br /> South O Test Well <br /> oatisa.aa.mama�a.e A.er.> ae Mme.. OVapor Extraction <br /> nw.re KKaaA D...ee.rp.p.asomew. <br /> 1, 00ther <br /> Water Level and Yfeld of Completed Well <br /> Depth to first water (Feel below surface) <br /> Depth to Stage '71 <br /> r <br /> Water Level I.0 (Feet) Date Measured 2� <br /> Total Depth of Boring Feet Estimated Yreld' / (GPM) Test Type <br /> Total Depth of Completed Wag A/ Feet Test Length (Hours)Total Drawdown_(Faet) <br /> °me not be representative of a well's long term yield. <br /> Casings Annular Material <br /> Depth from Borehole Wall Outside Screen Slot Size Depth from <br /> Surface Diameter' Typo Material Thickness Diameter Type If Any Surface FIII Description <br /> Feet b Feet, Inches Inches tlres Feel Is Feel <br /> i <br /> t <br /> Attachments Certification Statement <br /> ❑Geologic Log N the urMerslSne �rGN I¢a is ism Iprla andaccumle to the best of my knowledge and belief <br /> ❑Well Construction Diagram �PW�, �S �t_I` <br /> ❑Geophysical Logs) 23(%SP Wf9WA`"94 'Q r, fU UCtrA4 CA 4? 52.05 <br /> ❑SoiyWeler Chemical Analyses rasa err sista zip <br /> C3 Other signed(�t�,bw! �vrW�S�PrPe�sr�en 7(Z4(01 U 3G 3137 <br /> 1 car cuesudwebrwwcaa"sear Dale Signed C-57 License Number <br /> own IN REV.1n0% M ADDRIONAL SPACE 13 NEEDED,USE NExr wtISECURVELy NDMIERED FORM <br />