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'The free Adobe Reader may be used to view and complete this form However,software must be purchased to complete,save,and reuse a saved form. " <br /> File Original With DWR c State of California DWR use Ohly''Do Not Fill In <br /> paga�= of T - Well CompletionReport <br /> Referro laslruramprtlet- Slate Were NumberlSite Number <br /> Owners Wel!Number. - No. 756181,9 8 N W <br /> Date Work Began 0 Date Wark Ended - a Latitude Longitude <br /> Local Permit Agency <br /> Permit Number Permit bate-=262.— APNlTRslOther <br /> :Ge0yog is LM. <br /> Orierrtation •Vertical O Horizontai .OAngte: SPZi ; Name <br /> Drilling Nlcthod Difili++g Fluid Mailing Address <br /> Depth froth Surface ': Desq iptioti CIE State <br /> Fast,:: <br /> let' lo:s:'Feet- -OBscrfbe maleiiai rein site celnr etc <br /> 040 40 <br /> We11;11LocBtioliw:- <br /> linAi n _ Address 1 2-J <br /> r ` F city Q: n -- County larA414116 <br /> Latitude r N Longitude � $. <br /> Y 1 Dea. W. See, Data. Rrl. Sac. <br /> Datum Decimal Lot. Deuimal Gong.-14-1-19 <br /> APN Book,2(o Page 020 Parcel'.. j :--- - <br /> r <br /> Township_ Rariue BE- Section ° 9 <br /> Lactloti 5ltetcri <br /> Activi <br /> 5k�idr 0.1a etdieiMr "hand enertorm is rimed.', ONow Wall <br /> N6r1h .Q Modification./Repair <br /> O Deepen <br /> '00th <br /> er <br /> - ®Destroy <br /> • i { - wmtm pree.durae ane mste9ele- <br /> - as,der'SEtlLaaIG LOe• <br /> O Water Supply , <br /> 49�t( , •..: ©Domeslic ❑Pubkc <br /> W ❑itrfgation ❑Industria[ <br /> O Cathodic Protection <br /> O Dewatering <br /> - O Heat Exchange <br /> 0 Injection <br /> B_liLuSy lane zs 3$3`�oF M�WS O Monitoring <br /> O Remediation <br /> O'paging <br /> scum O Test Well <br /> Wrtrelecr4—toe dew:wet-0 om on ,wmfns•,r•�-. O Vapor ExtractlOn <br /> riren,efc.an9 alladra rnaP.use aadenriai Paperdneceasary. O Other. <br /> Pleere tN eccurneand ems tela. <br /> a titer Level and Yield ti#-C4'in feted WpU°'�.-z--'- <br /> _ - Depth to first water (Feet below surface) <br /> 1 Depth to Static <br /> Water Level (Feat) Date Measured <br /> 1. <br /> Total Depth of Boring Feet ` Estimated Yield• (GPM) Test Type <br /> L - Test Length (Hours)Total Drawdown _ (Feet) <br /> Total Depth of Completed Well Feet *May not be re resentarlve of a well's long term yield. <br /> 5.. <br /> Annular Material <br /> Crim <br /> Depthfrom '- BoreholeWall Outside Screen Slot Size Depth from <br /> Surface Dlaetai'': Material <br /> mThickness Wamater Type if Any Surface Fin Description <br /> Feet to Feet inches Inches Inches inches Feet to Feet <br /> l � ¢ <br /> e - <br /> ❑Gecltogic Log ttaahtnents _, C.ertltication Statement: t <br /> 1,the undersigned certify that this report Is complete and accurate to the best of my knowledge and ballet <br /> Name Qaoc-aAo.nrill inv T. P <br /> ❑Wall Construction Dlagram Pam=.Fi - <br /> mcorporation � i <br /> ❑Geophysical Log(s) , JQ2 m Cir Rancho rCordov� CA _ 95742- <br /> El <br /> 574 _ - <br /> ❑Soil/Water Chemical Analyses Ad city scala Zip <br /> ❑OHler Sldnedr 08/14/12 - 938110 <br /> Allach addttknat lydormetlan!fit sta, 57Lkcenced a resell Ir iae - Date Signed C-57 License Number <br /> DWR 188 REV.112COS IF ADDITIONAL SPACE IS NEEDED,USE NEXT CONSSCUnVELY NUMBEAED FORM <br />