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'The free Adoba Reader maybe used to view and complete this form. However,-software must be purchased to complete,save,end rouse 8 saved form. , <br /> File original with DWR State of Eallfornia :-.bWR Use onl -Do Not Fin Id' <br /> Page�� <br /> of L Well Completion Report <br /> Refsr 10lnslWootrPampMar State Well MumberlSile Number <br /> Owner's Well.Number — No. e015$490 N w <br /> Data Work Began Data WmkEnded Latitude Lon dude <br /> Local Perm€t Agency tAPN/TRSlarner <br /> Permit Number Perm t Date <br /> Geolo "ic a " Wall Ownet ' <br /> Orientation OVertical 0Horizontal OAngle Speclry .. Name.,(��,iN7�1l.n <br /> DriAing Method Drilling Fluid_ Ma€lin Address 'Gl <br /> Depth lrohi'.8urface Descrigtlorl CI State ru11 94 n�0 <br /> Feet;:.-40• Feet Describe material' Cain size,cpfor,std. <br /> 35 C6Ad A -11 <br /> -Well LoCatIOrS" <br /> Address ' 1 <br /> City Iz-C= County�.�Sr.n rJrir�tn�.JV i <br /> t atitude ,. N l ongitude r.�t =' <br /> Den, Min. Seq. Dec. Mips. .Sac <br /> DatumIVADR?� Debknal Late`Dacirrt�l"hong: t���R <br /> x APN books Palle_ _ �] ParceE',. 2 <br /> Townshipe' <br /> Ran seclion`�9 <br /> Location Ski#cFi':•": ACtWit + <br /> sketdhuhiisttiedrawn handat6r.raifito "led. O'Now Well <br /> North O-Mod€fleationlRepair <br /> 0 Deepen - <br /> " ' O Other <br /> Destroy . .._. _ # <br /> oesad6o pnweurca and mntede" 4 <br /> urrder-r�tlLO61C LOG' <br /> ' -piariiied 060 t <br /> !►A1N-11 ' O Water Supply <br /> ❑DomOSUc (,]Public <br /> []irrigation []industrial <br /> 0 Cathodic Protection <br /> 5(- O Dewataring <br /> © w O Heat Exchange <br /> 0 injection <br /> r r - O Monitoring <br /> t N y�y_ O Remediation 3 <br /> i.-GtIC+S.�r <br /> R 1:9 3pprwd 1�1w-t1 O TegstW�I <br /> South <br /> E,aaare w deeenedde„m araet r m mea.,a ikflnw,rw cs, O Vapor Extraction ! <br /> rNan,ai.and armhamap.Use aMitanalpapeiffnam46ery. O Other <br /> - pleaseheexurale and cam lek- <br /> aizera;evil and Yield.of.Goin'leted Well;''" <br /> Depth to first water (t=eat below surface) <br /> Depth to Static <br /> Water Level (Feet) Date Measured <br /> Tata!Depth of Boring Feet Estimated Yield' (GPM) Test Type <br /> Tota!Depth pt`Completed Well Feet q Test Langth (Hours)Total Drawdown (Feel) <br /> *May not be representative of a well's long term yidd. <br /> Casln&"-: ',; '.. _`.: , Material <br /> De lh from 66rahofe Wall Outside Screen Slot Size Depth from <br /> r Surface DlamatO Type ,Material .Thlekness Diameter Type If Any Surface 'Fill Descrlpllon <br /> Feet ro Feet (Inches ' nches Inches nches Feet` to Feel <br /> El <br /> : .AttaDitments_':.'' : " :, Certifioat€onSte'tement. <br /> ❑Geologic Log I,the undersigned,certify that this report is complete and accurate to the best of my knowledge and bellef <br /> ❑Well Construction Diagram Name cascade DL;7 1 jngT. p -- <br /> r Parson,Finn or Corporation <br /> t 0 Geophysical Log($) ompnCA K7 <br /> Rarh� QnrdQyA_ 4d9 <br /> 11Soli(Water Chemical Analyses Addm city slate zap <br /> ❑Other Signed 08/14/12 936110 <br /> Attach add)IEmml ldrMatlm Yd exretx 857 Neensed atarwe8 co c r a pate SI ned C57 License Number <br /> DWR 188 REV.112008 — _ IF ADDITIONAL SPACE 13 NEEDED,USE NE)(r O0NSECU-f1VELY NUPIRPRFD FORM <br />