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'The free Adobe Reader may be used to View and complete this form. However,sanware must be purchased to complete,save,and reuse a saved form. <br /> 4. <br /> File Original with DWR I. State of Californla, DWRUse0nIv,5DoNdFI1lIn r <br /> Page of Well Completion Report <br /> Rararfo InsUecUoaPamyhrel Stala WCII NumbedSlte Number <br /> I Owner's Wall Number 11/1 11 A X10, 6015 '105 I IWI <br /> Date Work Began Q -l2 Date Work Ended t Latitude W It de <br /> G :Local Permit Agency `i' t <br /> Permit Number �� Pe it Date APwiRsfOther <br /> � <br /> Geolo ic.Lo W$II'Oti7jio�:- <br /> E Orientation •Vertical O Horizontal OAngte 8PDQYY-----1LName <br /> Drilling Method Drilling Fluld <br /> Depl!N from SU'rface Description Mailing Address <br /> 1 Feel;','b. Feet Da5ailhe meteifsl. rain stie,cc[or,elc city state-CA-Zi �LsuSi._ <br /> 30 Ovem&616A .,a4 110-0 <br /> 1.: Well`Lbca#i6f5 <br /> Address t' <br /> City r Caurity <br /> Latitude N Lorgllude _ '' <br /> 1. flan. MIn. Sec.'.. -Dae- Min. ''Sec <br /> I Datum DeciMal Laf. YJ -Decimal Ldmg. , t <br /> i. I;: APN Beak if_'Page�20 Parcel . <br /> 0 <br /> Q <br /> Township <br /> .r' r <br /> J. .. .' :'::'..�Qeatipn:Skett:h� <br /> sxaidiiivsteaat ty h i&M i, <br /> �172218d1Q New Well <br /> North O Mcidincation/Repair <br /> 41 <br /> r Deepen <br /> O Dt <br /> r - Destroy . <br /> b.suibe pp��ccuuddua.aed makeele <br /> Q Water Supply <br /> []Domestic; —]Public <br /> XW f=o(e Dlrrigation-©industrial <br /> O Cathodic Protection <br /> f <br /> O Dewatering <br /> O Heal Exchange - <br /> s O Injection <br /> O Monitoring <br /> rcx�y 1-t o is 3�8'I� 4 )AWO Remediation <br /> %,A is 420'-VJ CA WW-b O res�iNel <br /> e <br /> TM1[J; Soulh <br /> I rw.eal.ae,maeesunaeelrierr..m,badea.,rawes O Vapor Extraction <br /> f+am,ate.eM.M.by OP,u. da�ar P.P.lrax. wit O Other <br /> P*...IM.C—I...d Etl"lana <br /> Water Level:anti YIe0of'CoM letedWeil <br /> Depth to <br /> first we Fae <br /> t below surface) <br /> dace <br /> Depth to Static. ` ) <br /> t <br /> Water Level <br /> Feet Date Measured <br /> Total Depth of t3oring .L:Fe ,: I Estimated Yield•" (GPM) Test Typo <br /> Total Depth o l <br /> Test Length (Hours)Total Drawdown (Feet) <br /> F Corn eted Well <br /> P P <br /> Ma not beres ti <br /> enta ve of a well's Ion term ie d. <br /> II� <br /> I <br /> lar Material Depth from aorshnle Wall y Outside::a''Screen Slot Size r" De th franc i' <br /> Type mate" 1 i P , <br /> surface Plemeter.. - Thickness Dlamater"I� Type if Any Surface Fill Description <br /> Feet b Feet Inches - " riches Inches - ndrgs Feet to pest <br /> F <br /> 1 <br /> -Atta6Firrt6nts . . �: <br /> Certlfication Statesrient.': . . <br /> D Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> ❑Well Construction DiagramName <br /> ❑Geophysical Log(s) Persnn,Firtno corporatlan i' <br /> CA 95742 <br /> Soil/Water Chemical AnaFyses Aa a City Stam 7rP <br /> ❑Other signed _ tf 08/14/12 938110 , <br /> 1, ch adddimml'nfo seen - C-5T Licensed Wever W ontradd r Date Signed C-57 License Number <br /> DWR 188 REV.112006 IF ADOMONAL SPACE IS NEEDED;115E NEXT CONSECUTIVELY NUMBERED FORM <br /> I <br /> f <br /> h <br />