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U <br /> 'The hee Adobe Reader may he used W view and complete Nis form However,solhWuS must be purchased to compete,save,and reuse a saved form. <br /> File Original with DWR, Slate of California DWR Use On —Do Not Fit In <br /> Page Of Well Completion Report <br /> M r',^ n n.o. e00 54 hamavr State Well NumbedShe Number <br /> Owner's Well Number W rt No. app 5 95 rr��TT <br /> g <br /> Dale Work Began 7 23 9 Dalew enQed Z� ZOd Latitude Lo hMa • <br /> Lacal Pemlit Age r4rl A V <br /> Permit Number S Permtl Dale q <br /> I <br /> Geologic LouWell Ow er <br /> V I Horizontal OAngle sp�eary <br /> WS Dulling Fluld ry Name— <br /> ,,4=nOS CIt <br /> Depth from Surface Description Mating Atltlreso ZZ r Ttnd Wile <br /> Feel b Feel DeebibB material nsue,cobr.¢Ic,.,_.,. Cil tt/ state i 5 <br /> Well Location <br />! es L(rf-\ MW^ AddressFa <br /> City. 14'/A�N Cl4 Counly�44'1 . <br /> ►1/ S lht Latitude __ N Longitude_____y <br /> oss. Aan sae, 7 cL <br /> r, 1 d Datum Decimal La1.3/, 1 Dedmal Long. 121.$7 <br /> APN Book23 3 Page :57 Parcel 00 (J' <br /> TOWnshi Ra Section <br /> Location Sketch Activit <br /> d ssew nw beemm hmdaflaromb kd. ONew Well <br /> North <br /> _ 0 Modificagon/Repalr <br /> 0 Deepen <br /> Sbl, CQ 0Other <br /> Destroy <br /> u,w�aas,c ren• <br /> "qRPlanned Uses <br /> 0 Water Supply <br /> F ❑Oomeafic []Public <br /> 3 ❑Irdgation ❑Industrial <br /> 0 Cathodic Protection <br /> 0 Dewatering <br /> 0 Heal Exchange I <br /> 0 In)eGbn <br /> 0 Monitoring <br /> 0 Remediation <br /> - EA S r I Iri'1. 0 Sparghg <br /> South <br /> 0 Test Well <br />� - some>eaaa muaoa.,e aa,,,.a,wAegq t.�, OVapor Exlredion <br /> ow,:s:.'aw•e`a, wmamn+ow r,R.w. 0Olher <br /> - Water Level and Yield of Completed Well <br /> - - Depth to "ter ter (Feet below sudsce) <br /> Depth to first 1 <br /> Waley Levet I0 (Feet) Date Measured 7I Z 3l d IG <br /> Total Depth of Boring Feet Estimated YieldN I ft (GPM) Test Type <br /> Total Depth of Completed Well M Feet Test Length (Hours)Total Drawdovm_(Feet) <br /> *Mhaynotbarseresentativeofawell's Iona lens yield. <br /> Casings Annular Material <br /> Depth rrom BoreholeWeil Ouhlde Screen Slot She Depth from <br /> Surface Diameter j Type Materiel IThICkneas Diameter Type If Any Surface Fill Description <br /> Feel wf Feel Inches Inchesl (Inchesl Feet is Feet <br /> i <br /> Attachments Certification Statement <br /> ❑Geologic Log I,the undeptpn i�r tbal{hIs raped�s tete and accurate to the best of m knowledge and ballet <br /> ❑Well Construction Diagram Name_ NN 5 (/Vl `1WW1 ra- I Y 9 <br /> ❑Geophysical Log(s) �fp 'Tgec'�ia"�pi'n Or. S ek1lTM en 9'5206 _ J <br /> ❑Soil/Water Chemical Analyses m air Stela ap <br /> M� 41,wzc 1 Pr'et;Sik4 r� zy/a9 a 36 3!7 <br /> ee,1i6M aiemta car Lcaueewmar ver Canaaaor <br /> Dole Shined C57 License Number I <br /> MR tae REV.local IFADORpNAL SPACE IS NEEDED,USE n CON IYELY NUMBERED FORM <br /> J <br />