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�5 <br /> ' 1 <br /> "The free Adobe Reader may be used to view and complete this form. I lowover,software must be purchased to complete,save,and reuse'e ea`ved form. <br /> File Original with DWR M 3 State of California <br /> I DWR Use Orly-:,06 Not Fill Irk <br /> Well Completion Report <br /> Page�� of _ Rarer to fndrudian Pamphlet <br /> State Welt NumberlSite Number <br /> OWneg's Well Number_�y/,�,W-5 __ No.e0158104 INIr-f I i itv <br /> Date Work Bogan ��� Date Work Ended Latitude Lo tulle <br /> Laval Permit AgaCrry ?4 , l~ v� � } <br /> APWIFRSIOther <br /> Permit atePennitJumberfinC <br /> . <br /> We Ill _ <br /> orientation O Vertica€ O Horizontal OAngte: specify Name, l <br /> Drilling Method m Drilling Fluid <br /> Maim Address 5csl Foej <br /> �-,y ', <br /> Qoptri-frorutface Descrlptioh Cit state i 6-t4 <br /> FeeE ti�-r-eet Dlascr ib6 in rein&b.calor,elcr, <br /> t 'Well LovAldw,- <br /> $t Address 102-Z Ernj&xs �r--_ ryA- <br /> City R;.nrrr► -CoolyShiYk i <br /> x Latitude 4 N Longiiu� L <br /> . , Dag. Mia Sac: - 'nap. Mln. .Sec. <br /> DattmlNAQA1 Decimal Loh rJ2'Decimal L6ng:12_1") 9 <br /> APN Oook Q('L Page, Q= <br /> i <br /> Township <br /> :LoCetipr Sketch ;iAwtivi <br /> t sl�t�in�sibedrewr 15ndanerromiis tiled.) O New Well <br /> NOS O MactificationlRepalr' <br /> e t O Deepen , I <br /> € m r O other - <br /> 1 Destroy <br /> nC,ri umiflar a <br /> maaGEGLDarCLOG- <br /> : <br /> O Water Supply s <br /> [:I Domestic❑Ptiblie` <br /> Dlrrigation []Industrial <br /> r _m 1 <br /> Q Cathodic Protection <br /> :.. a O Dewatering ' <br /> 160IN d KW O Heat Exchange <br /> ' 5rb1d¢�e Rad-S JZIWa t••�' 0 Injection <br /> O Monftoring . <br /> 5 t O Rernediation r <br /> ¢ _ : O Sparg€ng <br /> South Q Test Well t <br /> ° <br /> .drlca, O Vapor ExlracUon <br /> _. -eu6lala Mlle:uan eGela oi,wieamroaae.aAHlnya <br /> - .d5�.las+ne>„larhemap.p.Iue.essa,rwwrYnacesm.y- O other - - - <br /> Pi...h.--ft-doom lain <br /> ater Level and Y 0100 0f;Com leted Well <br /> ' Depth to tient water (Feet below surface) <br /> Depth to Static <br /> t Water Leval (Feet) Date Measured 4 <br /> Total Depth of l3onnd Feet Estimated Yield• (GPM) Test Type <br /> Test Length (Hours)Total Drawdown (Feet) <br /> Total Depth of Completed Well Feet , Way not be re resentative of a well's long termeld..' t <br /> Casln s <br /> Depth from 9orehole .Type Material WaIE Outslde Screen Slot Size Depth from <br /> Surface' Diameter. Thickness Diameter Type R If Any Surface FBI Descrlptlon <br /> Feet to Feet nches Inches) llnchml rinLhe2) Feel to Feet <br /> - 6 <br /> � 1 <br /> Attachments Certification Sfatemerit <br /> ❑Geologic Log I,the undersigned cerllfy that this report Is complete and accurate to the best of my knouliedge and belief <br /> Name r?cram ilrillinn T.,P. _ <br /> 11 Well Constructlon Diagram . Person,Fin or Corporahan r ; <br /> ❑Geophysical Log(s) a "a 3632 Qm c CircL Rancho Cordova QA 957,42 <br /> ` `❑SolllWator Chern€cal Analyses 0:1 Addslerwel city W845 Zip <br /> Sig nod D8/14/12 38110 <br /> a E31rnTGnnBlan If 3iatl Lkenhe whDate SI ed C-57 License Number <br /> DwR 199 REV.V21109 tF ADDITIONAL SPAGE M NEEDED,USE NEXT CONSECIfnVELY NUMBERED FORM <br />