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f <br /> 'The free Adobe Reader may be used to vlow and complete this form. However,software must be purchased to cornplate,save,and rause a saved form" <br /> File Original with DWR - State of California DWR Use Ont -=DoNot Fill in- <br /> Page — of Well Completidn Report <br /> Owner's Well Nurntler _ RefartatrutmctkmpamMol No. 801513103 State Well NumberlSiteNumber <br /> N w <br /> pate Work Began Date Work Ended ff2 ', latitude I_on etude <br /> Local Permit Agency <br /> Permit Number Permit o to�? /92aPNrrasfosner <br /> Gealo' Ic Lo"' 1NeIt afAtnar : <br /> Orientation •Vertical O Horizontal OArgle specify Name <br /> Drilling Method ,r Drilling Fluid <br /> Depth froth surface Description. Mallin Address <br /> '.Fest ts'..Fe'et .pei3cr16e.mateHal,-rainslzetc Cit StBte`SL]_LI . <br /> ;y.—' :Well l.tidatlbo . <br /> r: Address <br /> City <br /> r Cbunty scan IS=11e1 13 IA <br /> ,. .- <br /> Latitude _ N Longitud .Z(] w <br /> Dag" Min. sea'. "Vem MLn. 'Se- <br /> i <br /> Datum Decimal Lat:.� �"--peclmal Ling: <br /> r- r „ APN Book ' C 1.-I"Page parcel � -. <br /> i hip_,Ze_ Rarig.6 Seclien <br />' i ,-.` Location Sketch -:.` ,Acttvat .;-r,;`;•' <br /> I Slielch'mdE,t6eEtaidinh-.hand after formrs iln! Q NeW Well <br /> O ModificationlRepair <br /> Basi t ODeepen <br /> O other <br /> ® �y <br /> Des <br /> easaft Moedma errd matMah: <br /> j ..�• ^ - ender�GEDLaGIC IDs• <br /> O Water Supply <br /> ]Domestic i]Public <br /> 0Irrlgalion ❑Industrial <br /> • O Cathodic Protection <br /> g, ORewe <br /> tering K . <br /> O Heat Exchange <br /> Injection <br /> Q iSV).( O Monitoring <br /> 4rtPour) I's O Remadialion <br /> dtspensef2 H7 �%N_c- O Sparging <br /> 9Dutn O Test Well <br /> lam:tre[..rdesawede�aee.or,ra'rr�rr�r�s,aea<rn¢� O <br /> Vapor Extraction • <br /> rKw .0ta.aredaearharerep emidinUmemerc naysemy. O Other r <br /> ' _ Pieeae he gCCWe![end Wil feta: <br /> '. atoe.L.e"vel.aiiil Yfeld:o,Crim feted Well, <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> ' Water Levet (Feat) Date Measured <br /> Total Depth of I3aring Feet ,. Estimated Yield` _ (GPM) Test Type <br /> :Tota!Depth Of Completed Well Feel Test Length (Hours)Tote)Drawdown (Feet) <br /> 'May not be re resentatIve of a welts long term yield. <br /> :. Casln 5j. Af hilar Materlal <br /> Depot from ' .Borehole ..iype lNaterlal Wall Outside ;p Screen slot alxa Dapth from <br /> Surface Dtametdr . Thickness Diameter rt Type if Any I Surface F711 Description <br /> Feet to Feel IncNas Inches Innes 0-:1! Inches Feet to Feet <br /> L <br /> 4 <br /> Attachments: _ �• ;Ce11ItTcaCeon Statertt8rit.� <br /> l <br /> LJ Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my krlowiedge and belief i <br /> U Well Construction Diagram x Name Cascade Dri <br /> ❑Geophysical Log(s) Person,Fpm orcarpmation' i, t <br /> 3LU orneqAQircle ,Rancho Cardoy4 C95742 <br /> 0 SoillWafer Chemical Analyses Ad coy sista ztP <br /> ©other SignedInLw=bx, 08/14/12 938110 <br /> Attoch eddiUmal lnforrnallon If sexists C-57n eterwel Conlraoi& Date Signed C-57 License Number <br /> b4VR tea REV.V2009 IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSEONVELY NUMBERED FOAM <br /> 1 <br />