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I <br /> ( , <br /> The free Adobe Reader may be used to Antacid complete this form. However,software mast be purchased to oompiele,save,and reuse a saved form. <br /> He Original with OWR Slate of Caliromla DWR Use Only-Do Net Fm In i <br /> Well Completion Report <br /> Page of 1, 1 RN to�ParlMYerSlate Well <br /> Owner's Well Nlunher W 5 No. 0954 1 - (��� <br /> wn <br /> 1 Dale Work Began �- O`! Dale Work nde 2441 Latitude Lan aria <br /> r dC <br /> Local Permit Agency do G4M ✓u r/. <-al <br /> Pemtit Number 057777 Permit Dale - ��� APN(TRS/Oaer <br /> Geologic Log Well OWner <br /> Orientatlon VeNcal OHodzontal OArlgle spa��cdt`yv Name 5 Af/ <br /> Drdsng Alethm nBng Fluid N� Meitirg Address ZZ ,P <br /> Depth <br /> NA lG(OIuNA%G <br /> Depth from Surface Description <br /> ar_•'t Fool re Feet Describe malerlel,grain size oder.etc GI Siete I 95383 <br /> Well Location <br /> QS Ia-1 Address Cis <br /> City 4�L County SA"I JPiiA%" 1 <br /> 1`PiP111 (/1('1 IPI Latitude NLongitude__�y <br /> ,�,) (1 Datum oea DmaI La. 37t7'fo D Dm <br /> Long I LI well J <br /> APN Book 23 3 Page �T 7 Parcel 00310" <br /> WIQ <br /> Township-Range Section <br /> Location Sketch Activit <br /> ,C I bklimW Haman Madan/lam is ma. ONew Wen <br /> L.. .. North O ModificalbrJRepair <br /> O Deepen <br /> 5 Hw•S Destroy w �e <br /> wernEaoaclm <br /> Planned Uses <br /> O Water Supply <br /> ❑Domestic ❑Public <br /> ❑Irrigation ❑Industrial <br /> O Cathodic Protection <br /> ODewatering <br /> O Heat Exchange <br /> O Injection <br /> -^� <br /> O Monitoring <br /> 1 11 51#-4 ' O Remediagan <br /> O Sparging <br /> Scum O Test Well <br /> werva.oeesrwr.a am„n.s,was,y rem.. O Vapor Extraction <br />(. - - ,.m eewa�e.mw uw.aeeewleweeae®er1 OOther <br /> ater Level and Yield of Completed Well <br /> Depth to aml water (Feel below surface) <br /> Depth to Stalk I� <br /> Water Level cr1ID (Feel) Data Measured 7(23/01 <br /> Total Depth of Boring Feet Estimated Yield' N (GPM) Test Type <br /> Total Depth of Completed Well Feel <br /> ��1 Test Length (Hours)Total Drawdovm_(Feel) <br /> �('T <br /> 'May not be re resenlative W a well's lonq term yield. <br /> Casings Annular Material <br /> Depth from Borehole Type Material Wall Outside Screen Slot Size Depth from <br /> Surface Diameter ' Thickness Diameter Type If Any Surface FIII Description <br /> Feet m Feel (inches) Inches Indws) ---(MchesL Feet a Feet <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the under) %,�ed N tF+at Is re rt is�plete annd acourale to the best of my knowledge and belle! <br /> ❑Well Construction Diagram Name I,, SS O <br /> t 1 <br /> ❑Geophysical Log(s) rrWONl YS-fVa k ,CA <br /> S <br /> ❑SoillWaler Chemical Analyses „r1,/t / (t _ r�/A _ cin sale <br /> ❑Other Signed UMS (kCEN(L4 7(zfla9 —&-?G30 <br /> Amdlaaeemaarmneam yae,m osr LkwaeawmerwwcoNeda Dale Signed Cfi7 License Number <br /> DNR in REV.1/100 FA(xuln KSPACE IS NEEDED.USE NEXT CONSECUTIVELY NUMBERED FORM <br />