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' and reuse a saved form. <br /> 'The free Adobe Reader may be used to New and complete this form Fimvever,soilvrare mull!»purchased b complete,save, <br /> Foe Original with OWR State of California DWR Use On -Do Not FD in <br /> Well Completion Report <br /> Page of --I _� Rekrb Nvru Paapw Stale Well Numberluo Number <br /> Onmer's Well Number M1'1 No e0095480 - <br /> Oate Work Began 7 Date W ErKW 23 200, - Latitude Lniikude <br /> Local Permit Agency A r%L1�n cM✓, G I I I I i I I t I <br /> Permit Number 5/2 0 5 777 7 Permit Dale f2O0 APN/IRSltHller <br /> Geologic Log Well Owner <br /> Orientation Vertical OHoiizonial OAngle Spar* Name PLUM $ ow <br /> DriotngMettbd w5{-12un DdGngFluid It 1- Tuo1LLlN F <br /> Mailirg Address <br /> Depth from Surface Description <br /> Feet to Fad[ Describe maledal, In size color ek CII TIA/fM In G v'F Slate`i^L2i 5 3 J <br /> Well Location <br /> Wta dJ��"Ctlall M W- Address - <br /> city th <br /> County stµt C�019VI <br /> QVr COW L4 Latitude N Longitude__Ft_W <br /> 0¢a. Nn Sac 0¢o. Nn aos. <br /> atkA ta!CVQt I I 00rGAId I f- Datum , Z Decimall.81.37,740 Decimal Lon`•(2.(a 4th <br /> APN Hook 2-33 Page 37 Parcel OO� <br /> W t ffA Township Ran22 Section <br /> Location Sketch Activit <br /> V (, sVwai auatroarean twee clic lamrk 0New Well <br /> Nath 0 Modification/Repair <br /> O Deepen <br /> 60 t0. $W O Other <br /> 7j$ <br /> WDestmy <br /> . .w•aEowarctoa• <br /> Planned Uses <br /> 0 Water Supply <br /> ❑Domestic ❑Public❑Irrigation ❑Industrial <br /> O Cathodic Protection O Dewatering <br /> 0 Neal Exchange <br /> J O Injection <br /> _ 0 Monitoring <br /> - - 0 Remediation <br /> �_ 0 Sparging <br /> ' South O Test Well <br /> w.eraa..e.cmoa..r rw.�t.u.m.Iron O Vapor Extraction <br /> nv.,ee..errA.wa.w wm,rEs.•r�.a.•..r, <br /> Other- <br /> Water Level and Yield of Completed Well <br /> Depth to fual water (Feel belowsurf ) <br /> Depth to Sudic i <br /> Water Level r (Feel) Dale Measured 7�Z 3�a <br /> Total Depth of Boring (p/� Feet EstimatedYield' (GPM) Test Type <br /> Total Depth of Completed Well N t4 - Feet Test Length (Hours)Total Drawdown_(Feel) <br /> Way not be more entative of a well's k term eld. <br /> i <br /> Casings Annular Material <br /> Depth from Borehole Type Malarial Wall outside Screen StotShe Depth from <br /> Surface Diameter Thickness Diameter Type IIMy Surface FIII Description <br /> Feel b Fact triches Inches Inches Inches Feel to Feel <br /> Attachments Certification Statement <br /> ❑Geologic Log I.the underRR'g�ad,ce(Cdy(hat ails re isoorpplgte end accurate to the best of my knowledge and belief <br /> ❑Well Construction Diagram - Name F+nC_C r 1 f GH �l Iyt't•�U YI'H A- <br /> ❑GeopnysicalLatta) Z3(asp-ii'rw°wilwk Py. sf3i r&IA CA "15206 <br /> ❑SoillWater Chemical Analyses ^ �,CS •5t'w <br /> ❑Other Signed <br /> Anadl i ra¢mM. GsrLmae¢wamrwn coMrxmr Data Signed G-57 License Number <br /> Own 188 REV.IMM IF ADO *eM.¢PAGE6 NEEDED,USE NEXT CONSECUTNELY NUMBERE0 FORM <br />