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*The free Adobe Reader may be used to view and complata this form. However,sa`tware must be purchased to complete,save.and reuse a saved form. <br /> Fite Original wllh DWR i State of California s 'DwR use Ont Do Not - <br /> i ,Well Completion Report <br /> Page__ of Rerarro lnarructtonYampfJar State Well NumberlSile Number <br /> Owner s Well Number(-�- No.e0158706 N w <br /> Date Work Began d �3,/�'L�_ Date Work Ended,(`} 2 �2� LatitudeLon itude <br /> Local Permit Agency - _ r <br /> PermitNurnbar' Permit a APNlfR5lolher <br /> Gea)o fC Lo Buell owriier: <br /> Orientation ®Vertical 0Horizontal OAngle Specify Name <br /> D[1Ging Method Drilling Fluid _ Mallin Addre53 <br /> Depth from Surface ". pescrlptiori <br /> P11A %3z:6 <br /> Feet tc .Feet Deecribe mateiial.' rain size,tdor-isEc.0 City <br /> 30 <br /> OyerAp ::..Wei ,Locatibn'.i <br /> lC. CLI k f!OYAddress I <br /> city R-peka County <br /> Latllude s31_ 4 N I.bngittld; $ '. <br /> - Pan. Min. -seo,, - Papa Mlin. rSec. <br /> DatumNADAI Decimal Eat, Qeclmal Long. <br /> APN cloak 2r�i Page Parcel <br /> Township Rang- Section 19'; ` <br /> - '.F.ocefloi�'Sketch, �AtSfiyiit � � <br /> Ske[ch crust tie drawn 'hand etlerlorm is ed 0—New Well <br /> { Nonh O ModlffcatlonfRepair' j <br /> t Q Deepen <br /> O Other <br /> Destroy <br /> Dft.1 o ara*wres and arahaaha <br /> undo MEMOGIOL <br /> e fYlWli-`} "PfBrined lyses <br /> O Water supply <br /> _ ❑Domestic ❑Public <br /> f _ . w "[]Irrigation CiIndustrial , <br /> O Cathodic Protection <br /> O Dewatering <br /> + - O Heat Exchange <br /> 'Srp e,`p/a oiikC �k�� O Injection <br /> Q Monitoring a. <br /> l t9I N P`W O Remediation r <br /> w iS'z9G rw>at Muf-1 °o f >M�I i <br /> _ South <br /> uucr+wo a..oaee:a�wwaar a�detil[d gs,mama O Vapor Extraction <br /> dress as erd eaecn a map.use cad mretp�.r r nacessa y. O Other. <br /> ` _ 'araa,�aaam+nt.aaawra .[.. # , <br /> ott6r.LdVel and Yield:of:Corn feted Well <br /> Depth to first water (Feet below surface) <br /> Depth to Static <br /> r + Water Level (Feet) late Measured <br /> Total Depth of Ating Feet a Estimated Yield*, (GPM).Test Type f <br /> Total Depth of Completed Well Feet ' Test Length (hours)Total Drawdown (Feet) ; <br /> *Ma not be resentative ora well's longterm yield. <br /> Afnular IVlateifal: <br /> r Depth from BoreholeWall Outside Screen &lot Slzo Depth from <br /> Surface' 'Disinter Type Material Thickness Diameter Type If Any Surface Fill , Description I <br /> Feet to Feet inches Inches Inches Inches Feel to Fact <br /> ❑Geologic log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and belief <br /> .0 Well Construction Diagram Names <br /> Person,Flom or Corporafon <br /> © <br /> k GeocircleRancho Cordv95742_ <br /> Soll/WalerChemical Analyses city - <br /> state rip- <br /> t ©Other Signed , 08/14/12 938110 - ! <br /> Atlaeh ed oneTlnrormalion ita'exiata. CS7Ll a sedwetarwea Contractor - Date Signed C-57 License Number <br /> DWR 1E8 REV.72888 IF ADDITIONAL SPACE Is NEEDED,USE NEXT CONSECUTIVELY NUMBERED FORM <br />