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.j <br /> { <br /> 'rhe free Adobe Reader may be used to view and camplote chis form. However,software must be purchased to completorsava,and rouse a saved form.. <br /> File Original with DWR State of California ".'DWR Use On -•Do Not Fill Irl <br /> Page 1 Well Completion Report <br /> Rararw Imin mm pampwvf7 <br /> Owner's Well Number 4 No-0158101 . Slate Well Numbed3ifs Number r <br /> N W <br /> Date Work Began Date Work Ended Latilude Lon Rude <br /> E.ocai Permit Agency,s`ar, .�ad rt'0' VA ria q: D4 .ij4jA& <br /> Permit Number Permit Date . OL�/�Z APNrrRSrOtner <br /> if <br /> Well Owner: <br /> Orientation GiVertical O Horizontal OAngle Specify­" " Name h1twPlirm <br /> i Drilling Method Drilling Fluid Mailing ACIdre55 �Sik,'.. <br /> he}ith'freirl Surfaee Deectipllon <br /> ,Da§crlbe rnaEerlaJ, rain-atia,color-etc- Git - N +yeS'+ State. Zi . <br /> f <br /> -. --I':' WellE.tTcatl6it"_ - <br /> Address.�o . FroYape RbriiA_ <br /> City,.� Pic, <br /> r LatitudeN Longitude: ' ', <br /> oen. mlm Segr. Deft. I/rut. ssa, <br /> it Datum NADR'A Decimal LDecimal Long.121..139 i <br /> APN Book9,ki '•Page Q Parcol <br /> j <br /> Township 2S :.Rari a Se'don <br /> E Loc0"""Sketch' Activit ' <br /> Sk�iclimueihadraJrrr "handalferfarmis'Rii+sd O New Well r <br /> NorFh <br /> 0.MlidiflcaBonlRepalc <br /> S}pY�+i GroanO Deepen <br /> tvtye't O Other <br /> >> ®Destroy A <br /> . .. a� DOM"prommd and ma00E <br /> uda'GEOLOeIGLOG' <br /> OD <br /> 3a Planned:Uses <br /> ._• <br /> ! Q Water Supply " <br /> ❑Domestic OPublic 4 <br /> 3 ❑Irrigation [Industrial <br /> Cathodic Protection <br /> ' r ` q� H Q Dewatering <br /> 33 f I— O Heat Exchange <br /> O Injection <br /> _,. ::. . Q Monitoring I <br /> Q Remedlatlon i <br /> away is 259 'L Q spaTing <br /> rruti'tagc Rand;5 s Z WWF MVl!Z. Q Test Well <br /> wevaeou <br /> waesopedatanoao+munamroaa�.am s.rmus 0 Vapor Extraction <br /> dve q.lc wd tlf.rha m.µu.n ddduas.t pp. ­Y. <br /> O Other <br /> plmua qs uaeurnla and eom tote.' <br /> .afe 1eviA0r dXld1d of Corti letW Well.. <br /> Depth to first water (Feet below surface) <br /> Depth to Statin; - ? <br /> Water Level (Feet) Date Measurod <br /> Total Depth of Boring Feet _ Estimated field' (GPM) Test Type <br /> ' Test Length (Hours)Total Drawdown (Feet) <br /> Total Depth of Completed Wall - Feet : <br /> *May not be re reseniative of a well's long term yield. f <br /> Casin s Anritllar A9aterlal <br /> Depth from Borehole 'Type Materia! Wall Dutslde ;_'Screen Slot Size Depth from <br /> Surface Diameter - Thickness Dtameter Jype IFAny 'S'urface Fill Deacr$rtlon <br /> Feet to Feet Inches Inches Inches r.., Inches Feel to Feet <br /> Attachments `.:;:Cerfificadon`$tatement <br /> ❑Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Wall Construct-ion Diagiram F Name Cascade Drilling, L.P. I <br /> Faison.Firm or Corporalian' <br /> ❑ <br /> Geophysical Log(s) 3632 Ornec C'rcl-e Rancho Cordova CA 95742, ' <br /> ❑SolYWater Chemical AnalysescEty Slats zP <br /> ❑Other 08114/12 938110 <br /> AitashadcliRnalIrformallon ItItwAete. G67Llcanwd VVBIBr wall coMrerlar Date Signed C-57 License Number <br /> DWR 188 REV.112W8 "- "' -„ IF ADI)TRONAL SPACE IS NEEDrD,USE NEXT CONSECUTNELYNUMBERED FORAM <br />